title: The surgical discharge summary: a lack of substantial clinical information may affect the postop treatment of rectal cancer patients.
abstract: OBJECTIVE
  The discharge summary is crucial for patient aftercare as it is the main document for communicating information on patient data between the hospital and the primary care practitioner. The aim of this study was to assess the completeness of hospital discharge summaries and to determine whether the inclusion or omission of specific items of clinical information may affect further patient care.
  
  
  METHODS
  A population based cohort study including patients with rectal cancer from April 1996 through March 1998 in the Munich region. Five hundred and thirty-seven discharge summaries were evaluated for completeness of clinical- and tumor-related information. In addition, the association between recommendation for (discharge summary) and initiation of adjuvant therapy after discharge was evaluated.
  
  
  RESULTS
  Information about T and N category was given in 98%, about metastasis in 90%, and about residual tumor in 73% of all discharge summaries. Follow-up was recommended in only 68% of the summaries. No adjuvant therapy was administered to 5/5 patients with N+, T1/2 tumors nor to 14/17 patients with N+, T3/4 tumors if correspondent recommendations were missing.
  
  
  CONCLUSIONS
  Lack of crucial information in surgical discharge summaries is not only surprisingly common, but may also negatively affect patient aftercare.
authors.affiliation: Department of Surgery, Klinikum of the University of Regensburg, Franz-Josef-Strauss-Allee 11, 93047 Regensburg, Germany. johann.spatz@klinik.uni-regensburg.de
authors.forename: H
authors.initials: H
authors.lastname: Spatz
authors.forename: J
authors.initials: J
authors.lastname: Engel
authors.forename: D
authors.initials: D
authors.lastname: Hölzel
authors.forename: K W
authors.initials: KW
authors.lastname: Jauch
mesh_terms: D015331:Cohort Studies; D003142:Communication; D004282:Documentation / Q000592:standards; D006285:Health Planning; D006801:Humans; D008499:Medical Records / Q000592:standards*; D010351:Patient Discharge / Q000592:standards*; D011182:Postoperative Care / Q000592:standards*; D012004:Rectal Neoplasms / Q000601:surgery / Q000628:therapy*; D015203:Reproducibility of Results