Assessing quality and efficiency of discharge summaries.
Discharge summaries are intended to transfer important clinical information from inpatient to outpatient settings and between hospital admissions. The authors created a point scale that rated summaries in 4 key areas and applied the scale at a community teaching hospital over 3 years. Charts of 150 patients were selected equally from those discharged early and late in the academic year. Residents dictated all summaries after July 2003 using a prominently displayed template. Two residents and a senior physician assessed dictation quality. Considerable differences were found among raters, particularly in the evaluation of style. The average of the 3 raters' scores improved 21%, and dictation length decreased 67% after introduction of the template (P < .001). No relationship was found among service intensity (measured as chart weight), dictation length (measured in lines), and quality. Measured by a comprehensive rating scale, the quality of discharge summaries increased with use of a template while their length decreased.
Rao
Pratibha
P
Mountainside Hospital, Montclair, New Jersey, USA.
Andrei
Anca
A
Fried
Alvin
A
Gonzalez
David
D
Shine
Daniel
D
D003266:Continuity of Patient Care; D017598:Efficiency, Organizational; D005568:Forms and Records Control; D006764:Hospitals, Community / Q000592:standards*; D006784:Hospitals, Teaching / Q000592:standards*; D006801:Humans; D008499:Medical Records / Q000592:standards*; D009515:New Jersey; D015588:Observer Variation; D010351:Patient Discharge; D011785:Quality Assurance, Health Care / Q000379:methods*