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Abstract Details

Hospital Discharge Summaries: Lessons in Improvement
Neurologic 好色先生
P05 - (-)
006
BACKGROUND: A discharge summary serves as means of communication between the inpatient and outpatient healthcare provider after the hospitalization of a patient. The acute healthcare provider should compile a summary that is complete, concise, and error-free. It should reflect the assessment and care of the patient including diagnoses, details of diagnostic studies, treatments, outcome, and disposition. Multiple studies demonstrate that discharge summaries are frequently unavailable or missing pertinent information. We examined the effectiveness of using templates for composing discharge summaries.
DESIGN/METHODS: 30 discharge summaries over a 3-month period were randomly selected and reviewed for completeness using a checklist of twenty-five general admission information components including but not limited to history of present illness, past medical history, medications, allergies, etc. Areas of deficiencies were noted. Templates outlining the required items of a discharge summary were devised and implemented. Another 30 discharge summaries over 3-month period thereafter were reviewed and analyzed.
RESULTS: The rates of overall completeness were slightly improved after the implementation of the template (90% vs. 86.1%). The areas of review of systems, allergies, discharge medications, vital signs, and pertinent laboratory data had reductions in deficiency rates by 40%, 66.7%, 71.4%, 72.7%, and 90%, respectively. However, the areas of family history, disposition, and follow up instructions did not show significant improvement.
CONCLUSIONS: The implementation of templates improved multiples areas of previous deficiencies within the summaries. Stricter adherence to including all components of a summary as outlined in the standardized templates should be routinely emphasized to promote more comprehensive, and therefore, higher quality discharge summaries.
Authors/Disclosures
Jennie Valles, MD
PRESENTER 		No disclosure on file
Kiran A. Patil, MD, FAAN (Independence Health) Dr. Patil has nothing to disclose.
Michelle Molina, MD No disclosure on file
Jin Li, MD, PhD, FAAN Dr. Li has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Abbvie. Dr. Li has a non-compensated relationship as a member, woman leadership committee with AAN that is relevant to AAN interests or activities.
Maria Pia Sormani (University of Genoa) Maria Pia Sormani has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biogen. Maria Pia Sormani has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Roche. Maria Pia Sormani has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Sanofi. Maria Pia Sormani has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Merck. Maria Pia Sormani has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Bristol meyer. Maria Pia Sormani has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novartis. Maria Pia Sormani has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Immunic. Maria Pia Sormani has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Novartis, Roche. Maria Pia Sormani has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Sanofi. Maria Pia Sormani has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche.