Improving the discharge summary

There is a high risk for communication failures at the hospital discharge. Discharge summaries (DCS) can mitigate these risks by describing not only the hospital course but also follow-up plans. Improvement in the DCS may play a crucial role to improve communication at this transition of care. This research identifies gaps between the local standard of practice and best practices reported in the literature. It also identifies specific components of the DCS that could be improved through enhanced use of health information technology. A manual chart review of 188 DCS was performed. The medication reconciliations were analyzed for completeness and for medical reasoning. The pending results reported in the DCS were compared to those identified in the enterprise data warehouse (EDW). Documentation of follow-up arrangements was analyzed. Report of patient preferences, patient goals, lessons learned, and the overall handover tone were also noted. Patients were discharged on an average of 9.8 medications. Only 3% of the medication reconciliations were complete regarding which medications were continued, changed, new, and discontinued; 94% were incomplete and medical reasoning was frequently absent. There were 358 pending results in 188 hospital discharges. 14% of those results were in the DCS while 86% were only found in the EDW. Less than 50% iv of patients had clear documentation of scheduled follow-up. Patient preferences, patient goals, and lessons learned were rarely (6%, 1%, and 3% respectively) included. There was a handover tone in only 17% of the DCS. The quality gaps in the DCS are consistent with the literature. Medication reconciliations were frequently incomplete, pending results were rarely available, and documentation of follow-up care occurred less than half of the time. Evaluating the DCS primarily as a clinical handover is novel. Information necessary for safe handovers and to promote continuity of care is frequently missing. Future improvements should reshape the DCS to improve continuity of care.