Tuesday, September 15, 2009

Discharge summaries “grossly inadequate”

---according to this study.

Discharge summaries were available for 99.2% of 668 patients whose data were analyzed. These summaries mentioned only 16% of tests with pending results (482 of 2,927). Even though all study patients had tests with pending results, only 25% of discharge summaries mentioned any pending tests, with 13% documenting all pending tests. The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return. Follow-up providers’ information was documented in 67% of summaries.

These were academic medical centers which should have been exemplars of quality documentation!

In today’s push for “efficient use” of hospital resources we see more and more patients shoved out the door with pending test results. This is a huge problem.

Most discharge summaries nowadays are generated by templates. Popular templates that I’ve seen, whether paper-based or generated by the EMR, tend to lack sections devoted to pending test results and follow up needs.

Via Hospital Medicine Quick Hits.

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