School of Medicine and Health Sciences Poster Presentations

Title

Discharge Summaries: An Intervention To improve Standardized Requirements

Poster Number

324

Document Type

Poster

Status

Medical Resident

Abstract Category

Quality Improvement

Keywords

discharge summary, AHRQ, Joint Commission, Cerner

Publication Date

Spring 2018

Abstract

Medical doctors write discharge summaries every day, documenting a summary of the hospital encounter of patients. Despite the critical role that these documents play in transitions of care, whether it is to a nursing facility or home, they are often times missing crucial information and physicians get little to no training in the creation of discharge summaries during medical school or residency. The existence of Joint Commission standards mandating discharge summary components has made it such that all discharge summaries should include six pieces of information and missing even one component can jeopardize patient safety. This was addressed in a prior study at the University of Wisconsin where Dr. Smith, et al. reviewed the Joint Commission Standard Requirements for discharge summaries, particularly studying discharge summaries for subacute rehabilitation facilities. In their study, they found that the patient’s discharge condition was often omitted. Although the impact on patient safety is not clearly known, it is safe to assume that when patients leave hospitals and are unable to verbalize their medical condition, it is of utmost importance to have documentation of discharge condition in the only paperwork that often follows the patient to their next place of care. The purpose of our quality improve project was to assess whether providing a training session to internal medicine interns at the start of their residency improved those measures as outlined by the Joint Commission. By comparing discharge summaries from September/October 2016, prior to any training session, to those of September/October 2017, after training, we found that there was a roughly twenty percent improvement in inclusion of all the criteria. Our study shows that one teaching session during orientation, particularly for interns who have often times had no exposure to discharge summary writing, can be vital in promoting patient safety. This may serve as a foundation for all residency programs to provide such sessions dedicated to discussing the Joint Commission Standard Requirements for Discharge Summaries, and will also provide ground to create more specific components within discharge summaries that are crucial for transition of care.

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Discharge Summaries: An Intervention To improve Standardized Requirements

Medical doctors write discharge summaries every day, documenting a summary of the hospital encounter of patients. Despite the critical role that these documents play in transitions of care, whether it is to a nursing facility or home, they are often times missing crucial information and physicians get little to no training in the creation of discharge summaries during medical school or residency. The existence of Joint Commission standards mandating discharge summary components has made it such that all discharge summaries should include six pieces of information and missing even one component can jeopardize patient safety. This was addressed in a prior study at the University of Wisconsin where Dr. Smith, et al. reviewed the Joint Commission Standard Requirements for discharge summaries, particularly studying discharge summaries for subacute rehabilitation facilities. In their study, they found that the patient’s discharge condition was often omitted. Although the impact on patient safety is not clearly known, it is safe to assume that when patients leave hospitals and are unable to verbalize their medical condition, it is of utmost importance to have documentation of discharge condition in the only paperwork that often follows the patient to their next place of care. The purpose of our quality improve project was to assess whether providing a training session to internal medicine interns at the start of their residency improved those measures as outlined by the Joint Commission. By comparing discharge summaries from September/October 2016, prior to any training session, to those of September/October 2017, after training, we found that there was a roughly twenty percent improvement in inclusion of all the criteria. Our study shows that one teaching session during orientation, particularly for interns who have often times had no exposure to discharge summary writing, can be vital in promoting patient safety. This may serve as a foundation for all residency programs to provide such sessions dedicated to discussing the Joint Commission Standard Requirements for Discharge Summaries, and will also provide ground to create more specific components within discharge summaries that are crucial for transition of care.