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Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria
Author(s) -
Schwarz Christine Maria,
Hoffmann Magdalena,
Smolle Christian,
Eiber Michael,
Stoiser Bianca,
Pregartner Gudrun,
Kamolz LarsPeter,
Sendlhofer Gerald
Publication year - 2021
Publication title -
journal of evaluation in clinical practice
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.737
H-Index - 73
eISSN - 1365-2753
pISSN - 1356-1294
DOI - 10.1111/jep.13533
Subject(s) - conformity , completeness (order theory) , likert scale , medicine , content analysis , family medicine , medical record , pediatrics , psychology , social psychology , mathematical analysis , developmental psychology , mathematics , social science , sociology , radiology
Rationale and objective The discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations. Method One hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4‐point Likert‐type scale ranging from “strongly agree” to “strongly disagree” (or “not relevant”). Subsequently, the results were discussed among reviewers to achieve a consensus decision. Results The mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS. Conclusions In conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations.