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Clinical Feature

Optimizing the quality of hospital discharge summaries – a systematic review and practical tools

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Pages 630-639 | Received 05 Feb 2015, Accepted 20 May 2015, Published online: 14 Jun 2015

References

  • Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med 2012;157:417–28
  • Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297:831–41
  • Blum K, Muller U. Krankenhausärzte - enormer dokumentationsaufwand. Dtsch Arztebl 2003;100:1581
  • Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Aust 2008;188:506–9
  • Ammenwerth E, Spoetl H-P. The time needed for clinical documentation versus direct patient care. A work-sampling analysis of physicians’ activities. Methods Inf Med 2009;48:84–91
  • Gomez-Rosado J-C, Sanchez-Ramirez M, Valdes-Hernandez J, Capitan-Morales LC, Del-Nozal-Nalda MI, Oliva-Mompean F. Importance of the quality of the discharge report in the management of a surgical clinical unit. Cir Esp 2013;91:378–83
  • Cornu P, Steurbaut S, Leysen T, De Baere E, Ligneel C, Mets T, Dupont AG. Discrepancies in medication information for the primary care physician and the geriatric patient at discharge. Ann Pharmacother 2012;46:983–90
  • Franklin BD, Reynolds M, Shebl NA, Burnett S, Jacklin A. Prescribing errors in hospital inpatients: a three-centre study of their prevalence, types and causes. Postgrad Med J 2011;87:739–45
  • Wilson S, Ruscoe W, Chapman M, Miller R. General practitioner-hospital communications: a review of discharge summaries. J Qual Clin Pract 2001;21:104–8
  • Callen J, McIntosh J, Li J. Accuracy of medication documentation in hospital discharge summaries: A retrospective analysis of medication transcription errors in manual and electronic discharge summaries. Int J Med Inf 2010;79:58–64
  • Belleli E, Naccarella L, Pirotta M. Communication at the interface between hospitals and primary care - a general practice audit of hospital discharge summaries. Aust Fam Physician 2013;42:886–90
  • Al-Damluji MS, Dzara K, Hodshon B, Punnanithinont N, Krumholz HM, Chaudhry SI, Horwitz LI. Hospital variation in quality of discharge summaries for patients hospitalized with heart failure exacerbation. Circ Cardiovasc Qual Outcomes 2015;8:77–86
  • Mishra AK, Bhattarai S, Bhurtel P, Bista NR, Shrestha P, Thakali K, Banthia P, et al. Need for improvement of medical records. JNMA J Nepal Med Assoc 2009;48:103–6
  • Yemm R, Bhattacharya D, Wright D, Poland F. What constitutes a high quality discharge summary? A comparison between the views of secondary and primary care doctors. Int J Med Educ 2014;5:125–31
  • Heaton A, Webb D, Maxwell S. Undergraduate preparation for prescribing: the views of 2413 UK medical students and recent graduates. Br J Clin Pharmacol 2008;66:128–34
  • Weitz G, Friederichs H, Twesten C, Bonnemeier H, Lehnert H, Wellhöner P. Curriculare Übung zum Verfassen von Arztbriefen im vierten Jahr des Medizinstudiums – Einschätzungen der Teilnehmer nach zwei Jahren. Wien Med Wochenschr 2015;165:86–90
  • Frain JP, Frain AE, Carr PH. Experience of medical senior house officers in preparing discharge summaries. BMJ 1996;312:350
  • Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, Weiss KB, et al. Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. J Gen Intern Med 2009;24:971–6
  • Scottish Intercollegiate Guidelines Network (SIGN) [homepage on the internet]. The SIGN discharge document. 2012. Avialable from http://www.sign.ac.uk/pdf/sign128.pdf. Cited April 17, 2015
  • Health Information and Quality Authority (HIQA), Cork, Ireland [homepage on the internet]. National Standard for Patient Discharge Summary Information. 2014. Avialable from http://www.hiqa.ie/publications/national-standard-patient-discharge-summary-information. Cited April 17, 2015
  • Health and Social Care Information Centre, Academy of Medical Royal Colleges [homepage on the internet]. Standards for the clinical structure and content of patient records. 2013. Avialable from https://www.rcplondon.ac.uk/resources/standards-clinical-structure-and-content-patient-records. Cited April 17, 2015
  • Axon RN, Penney FT, Kyle TR, Zapka J, Marsden J, Zhao Y, Mauldin PD, et al. A hospital discharge summary quality improvement program featuring individual and team-based feedback and academic detailing. Am J Med Sci 2014;347:472–7
  • Bergkvist A, Midlöv P, Höglund P, Larsson L, Bondesson A, Eriksson T. Improved quality in the hospital discharge summary reduces medication errors--LIMM: Landskrona Integrated Medicines Management. Eur J Clin Pharmacol 2009;65:1037–46
  • Bischoff K, Goel A, Hollander H, Ranji SR, Mourad M. The Housestaff Incentive Program: improving the timeliness and quality of discharge summaries by engaging residents in quality improvement. BMJ Qual Saf 2013;22:768–74
  • Book K, Dinkel A, Henrich G, Stuhr C, Peuker M, Härtl K, Brähler E, et al. The effect of including a “psychooncological statement” in the discharge summary on patient-physician communication: a randomized controlled trial. Psychooncology 2013;22:2789–96
  • Clements D. An improved “interim discharge letter” a successful outcome from audit. J R Coll Physicians Lond 1992;26:169–71
  • Coit MH, Katz JT, McMahon GT. The effect of workload reduction on the quality of residents’ discharge summaries. J Gen Intern Med 2011;26:28–32
  • Dinescu A, Fernandez H, Ross JS, Karani R. Audit and feedback: an intervention to improve discharge summary completion. J Hosp Med 2011;6:28–32
  • Key-Solle M, Paulk E, Bradford K, Skinner AC, Lewis MC, Shomaker K. Improving the quality of discharge communication with an educational intervention. Pediatrics 2010;126:734–9
  • Kunz R, Wegscheider K, Guyatt G, Zielinski W, Rakowsky N, Donner-Banzhoff N, Müller-Lissner S. Impact of short evidence summaries in discharge letters on adherence of practitioners to discharge medication. A cluster-randomised controlled trial. Qual Saf Health Care 2007;16:456–61
  • Lampen-Smith A, Young J, O’Rourke M-A, Balram A, Inns S. Blinded randomised controlled study of the effect of a discharge communication template on proton pump inhibitor prescribing. N Z Med J 2012;125:30–6
  • Mathur R, Clark RA, Dhillon DP, Winter JH, Lipworth BJ. A repeat audit of hospital discharge letters in patients admitted with acute asthma. Scott Med J 1997;42:19–21
  • Medlock S, Eslami S, Askari M, van Lieshout EJ, Dongelmans DA, Abu-Hanna A. Improved communication in post-ICU care by improving writing of ICU discharge letters: a longitudinal before-after study. BMJ Qual Saf 2011;20:967–73
  • Midlöv P, Deierborg E, Holmdah L, Höglund P, Eriksson T. Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital. Pharm World Sci 2008;30:840–5
  • Mohta N, Vaishnava P, Liang C, et al. The effects of a “discharge time-out” on the quality of hospital discharge summaries. BMJ Qual Saf 2012;21:885–90
  • Myers JS, Jaipaul CK, Kogan JR, Krekun S, Bellini LM, Shea JA. Are discharge summaries teachable? The effects of a discharge summary curriculum on the quality of discharge summaries in an internal medicine residency program. Acad Med 2006;81:5–8
  • Russell P, Hewage U, Thompson C. Method for improving the quality of discharge summaries written by a general medical team. Intern Med J 2014;44:298–301
  • Stein R, Neufeld D, Shwartz I, Erez I, Haas I, Magen A, Glassberg E, et al. Assessment of surgical discharge summaries and evaluation of a new quality improvement model. Isr Med Assoc J 2014;16:714–17
  • Talwalkar JS, Ouellette JR, Alston S, Buller GK, Cottrell D, Genese T, Vaezy A. A structured workshop to improve the quality of resident discharge summaries. J Grad Med Educ 2012;4:87–91
  • Wolk A, Wang E, Horak B, Cloonan P, Adams M, Moore E, Jaipaul CK, et al. Effect of modest pay-for-performance financial incentive on time-to-discharge summary dictation among medical residents. Qual Manag Health Care 2013;22:272–5
  • Motamedi SM, Posadas-Calleja J, Straus S, Bates DW, Lorenzetti DL, Baylis B, Gilmour J, et al. The efficacy of computer-enabled discharge communication interventions: a systematic review. BMJ Qual Saf 2011;20:403–15
  • Wimsett J, Harper A, Jones P. Review article: Components of a good quality discharge summary: a systematic review. Emerg Med Australas 2014;26:430–8
  • Health and Social Care Information Centre of the U. K. Government, Leeds, U. K. [homepage on the internet]. Avialable from http://systems.hscic.gov.uk/clinrecords. Cited April 17, 2015
  • Penney TM. Dictate a discharge summary. BMJ 1989;298:1084–5
  • Pocklington C, Al-Dhahir L. A comparison of methods of producing a discharge summary: handwritten vs. electronic documentation. Br J Med Pract 2011;4:432
  • Schwarze M, Spallek M, Korallus C, Manecke IA, Teumer F, Wrbitzky R, Gutenbrunner C, et al. Advantages of the JobReha discharge letter: an instrument for improving the communication interface in occupational rehabilitation. Int Arch Occup Environ Health 2013;86:699–708
  • Kind AJH, Thorpe CT, Sattin JA, Walz SE, Smith MA. Provider characteristics, clinical-work processes and their relationship to discharge summary quality for sub-acute care patients. J Gen Intern Med 2012;27:78–84
  • Knaup P, Pilz J, Kaltschmidt J, Ludt S, Szecsenyi J, Haefeli WE. Standardized documentation of drug recommendations in discharge letters--a contribution to quality management in cooperative care. Methods Inf Med 2006;45:336–42
  • Eriksson T, Höglund P, Holmdah L, Bondesson A. Experiences from the implementation of structured patient discharge information for safe medication reconciliation at a Swedish university hospital. Eur J Hosp Pharm Sci 2011;2:42–9
  • O’Leary KJ, Liebovitz DM, Feinglass J, Liss DT, Evans DB, Kulkarni N, Landler MP, et al. Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. J Hosp Med 2009;4:219–25
  • Wass AR, Illingworth RN. What information do general practitioners want about accident and emergency patients? J Accid Emerg Med 1996;13:406–8
  • Parvaiz MA, Subramanian A, Kendall NS. The use of abbreviations in medical records in a multidisciplinary world--an imminent disaster. Commun Med 2008;5:25–33
  • Nietzsche F. Menschliches, Allzumenschliches II, 131 (1879). Köln, Germany: Anaconda 2006
  • Pietrzak P. Stylistic aspects of English and Polish medical records. Implications for translation. J Spec Transl 2015;23:316–32
  • Reinke CE, Kelz RR, Baillie CA, Norris A, Schmidt S, Wingate N, Myers JS. Timeliness and quality of surgical discharge summaries after the implementation of an electronic format. Am J Surg 2014;207:7–16
  • Walker CA. Dictated versus hand-written accident and emergency discharge documents. Emerg Med J EMJ 2007;24:67
  • Van Walraven C, Laupacis A, Seth R, Wells G. Dictated versus database-generated discharge summaries: a randomized clinical trial. CMAJ 1999;160:319–26
  • Maslove DM, Leiter RE, Griesman J, Arnott C, Mourad O, Chow CM, Bell CM. Electronic Versus Dictated Hospital Discharge Summaries: a Randomized Controlled Trial. J Gen Intern Med 2009;24:995–1001
  • Abbas M, Ward T, Peivandi MH, McKenzie E, Kujawska-Debiec K, Hills A. Quality of psychiatric discharge summaries: a service evaluation following the introduction of an electronic discharge summary system. Ir J Psychol Med 2015; FirstView 1–4
  • Callen JL, Alderton M, McIntosh J. Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries. Int J Med Inf 2008;77:613–20
  • Kirby J, Barker B, Fernando DJ, Jose M, Curtis C, Goodchild A, et al. A prospective case control study of the benefits of electronic discharge summaries. J Telemed Telecare 2006;12:20–1
  • Lieb K, Trieschmann S, Buhl C, Vielhaber K, Mehraein S, Härter MM. Accelerating consult letter time in inpatient psychiatric and psychotherapeutic care. Nervenarzt 2007;78:322–7
  • Eekhof JA, Heijmans M, Meskers-van Geel AA, Assendelft WJ. A snail leaves trails--how delayed provision of information affects the general practitioner and patient. Ned Tijdschr Geneeskd 2010;154:A2895
  • Li JY, Yong TY, Hakendorf P, Ben-Tovim D, Thompson CH. Timeliness in discharge summary dissemination is associated with patients’ clinical outcomes. J Eval Clin Pract 2013;19:76–9
  • Lenert LA, Sakaguchi FH, Weir CR. Rethinking the discharge summary: a focus on handoff communication. Acad Med J Assoc Am Med Coll 2014;89:393–8
  • The Royal Children’s Hospital Melbourne [homepage on the internet]. 10 Steps to a Good Discharge Summary. Avialable from http://www.rch.org.au/uploadedFiles/Main/Content/kidsconnect/10_tips_for_a_good_discharge_summary_2009.pdf. Cited April 17, 2015
  • Harris MF, Giles A, O’Toole BI. Communication across the divide. A trial of structured communication between general practice and emergency departments. Aust Fam Physician 2002;31:197–200
  • Kergoat M-J, Latour J, Julien I, Plante MA, Lebel P, Mainville D, Bolduc A, et al. A discharge summary adapted to the frail elderly to ensure transfer of relevant information from the hospital to community settings: a model. BMC Geriatr 2010;10:69
  • Legault K, Ostro J, Khalid Z, Wasi P, You JJ. Quality of discharge summaries prepared by first year internal medicine residents. BMC Med Educ 2012;12:77
  • Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. 2009;24
  • World Alliance for Patient Safety, World Health Organization. Summary of the evidence on patient safety: Implications for research. 2008:10–82
  • Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database Syst Rev 2013;1:CD000313
  • Horwitz LI, Jenq GY, Brewster UC, et al. Comprehensive quality of discharge summaries at an academic medical center. J Hosp Med 2013;8:36–443
  • Perera KY, Ranasinghe P, Adikari AM, Balagobi B, Constantine GR, Jayasinghe S. Medium of language in discharge summaries: would the use of native language improve patients’ knowledge of their illness and medications? J Health Commun 2012;17:141–8
  • Nielsen FT, Rosholm JU, Søndergaard J, Gohr T, Tougaard L. A short discharge letter with a copy to the patient--satisfactory for patients and practitioners. Ugeskr Laeger 1994;156:1811–13
  • Lin R, Gallagher R, Spinaze M, Najoumian H, Dennis C, Clifton-Bligh R, Tofler G. Effect of a patient-directed discharge letter on patient understanding of their hospitalisation. Intern Med J 2014;44:851–7
  • Schnabel K, Boldt PD, Breuer G. A consensus statement on practical skills in medical school – a position paper by the GMA Committee on Practical Skills. GMS Z Med Ausbild 2011;28:Doc58

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