title: Assessing quality and efficiency of discharge summaries.
abstract: 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.
authors.affiliation: Mountainside Hospital, Montclair, New Jersey, USA.
authors.forename: Pratibha
authors.initials: P
authors.lastname: Rao
authors.forename: Anca
authors.initials: A
authors.lastname: Andrei
authors.forename: Alvin
authors.initials: A
authors.lastname: Fried
authors.forename: David
authors.initials: D
authors.lastname: Gonzalez
authors.forename: Daniel
authors.initials: D
authors.lastname: Shine
mesh_terms: 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*