Using a multidisciplinary automated discharge summary process to improve information management across the system.
We developed and implemented an automated discharge summary process in a regional integrated managed health system. This multidisciplinary effort was initiated to correct deficits in patients' medical record documentation involving discharge instructions, follow-up care, discharge medications, and patient education. The results of our team effort included an automated summary that compiles data entered via computer pathways during a patient's hospitalization. All information regarding admission medications, patient education, follow-up care, referral at discharge activities, diagnosis, and other pertinent medical events are formulated into the discharge summary, discharge orders, patient discharge instructions, and transfer information as applicable. This communication process has tremendously enhanced information management across the system and helps us maintain complete and thorough documentation in patient records.
Crosswhite
R
R
North Mississippi Medical Center, Tupelo, USA.
Beckham
S H
SH
Gray
P
P
Hawkins
P R
PR
Hughes
J
J
D019033:Delivery of Health Care, Integrated / Q000458:organization & administration; D004282:Documentation / Q000592:standards; D001330:Electronic Data Processing; D006746:Hospital Bed Capacity, 500 and over; D006751:Hospital Information Systems / Q000592:standards*; D019451:Information Management / Q000592:standards*; D007324:Institutional Management Teams; D008500:Medical Records Department, Hospital / Q000592:standards*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D008922:Mississippi; D010351:Patient Discharge