Discharge summaries at the study institution are currently completed by house staff using a computerized system in place of a handwritten summary or dictation. The system was conceived in 1997 as a handoff tool allowing house staff to electronically update patient status daily to facilitate sign‐out between providers. In 2005, the system was updated to allow house staff to convert a compilation of these sign‐outs into a discharge summary to improve the timeliness of summary generation. More than 75% of summaries at our hospital are now completed using this system. Though converting daily sign‐out notes into discharge summaries has been feit to increase the ease of completing the summaries, concerns about the completeness and quality of these summaries have been raised. Kripalani et al. suggest that a summary at a minimum contain diagnoses, discharge medications, results of procedures, follow‐up needs, and any pending test results. We describe modifications that have been made with the intent of improving the quality of these summaries while maintaining the enhanced timeliness and efficiency of the system.
To modify the current electronic system in the departments of medicine and geriatrics to generate discharge summaries by house staff that systematically include all essential components.
The discharge summary capability of this electronic system was designed to generate a summary only at the time of discharge. The system utilized information completed from the handoff tool to populate fields in the discharge summary. Those fields include discharge diagnosis, problem list, history of present illness, past medical history, admitting exam, hospital course, procedures, and results. The system was modified to include real‐time discharge summary generation, where the “in‐progress” discharge summary can be viewed at any point during hospitalization. The revised version also consists of additional required fields, including discharge exam, medications, follow‐up appointments, and follow‐up tests and procedures. The new system also prints dated drafts of the summary to allow dissemination of information to patients and providers.
Providing the capability for a computerized sign‐out system to convert a compendium of daily sign‐outs into a discharge summary improved timeliness and efficiency at the perceived expense of quality. We have been able to make electronic modifications to the system to standardize the format of discharge summaries and encourage the systematic transfer of essential information. Data collection is ongoing to determine if the quality of discharge summaries has improved with the implementation of these changes.
J. Goldenberg, none; J. Mermelstein, none; J. Kannry, none; B. Markoff, none; R. Jervis, none; A. Dunn, none; N. Kathuria, none; A. Federman, none; A. Dinescu, none; B. Korc, none.
To cite this abstract:Goldenberg J, Mermelstein J, Jervis R, Markoff B, Dinescu A, Korc B, Kannry J, Dunn A, Federman A, Kathuria N. Speed or Accuracy? Seeking Both in an Electronic Standardized Discharge Summary Tool. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 115. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/speed-or-accuracy-seeking-both-in-an-electronic-standardized-discharge-summary-tool/. Accessed November 15, 2019.