Hospital discharge documentation are the primary documents communicating a patient’s care plan to the posthospital care team. Usually, it is the only form of communication that accompanies a patient to the next setting of care; often serves as initial care orders at a post acute care (PAC) facility. There is variability in the documentation that accompanies patients upon discharge to PAC facilities which leads to fragmentation of care, redundancy of work, and increased burden on the receiving institution to decipher what’s relevant. The Joint Commission has established standards outlining the components that a hospital discharge summary should contain, but there has is no standardization on the appropriate discharge documentation sent to PAC facilities upon a patient’s transfer.
To standardize the discharge documentation upon discharge to (PAC) facilities. To use an autopopulated post acute care transfer summary report which includes all the relevant documents & that documentation should be accurate, current, timely and free of extraneous and redundant information.
A group of hospitalists, nurses, case managers, and residents met with representatives from our most utilized PAC facilities to talk about the transfer process and elicit feedback on what they receive upon transfer versus what they need to care for a patient. We discussed pitfalls such as what may go wrong and issues that my prompt a clarification call. A tool was then developed in our electronic medical record to autoimport those elements into one comprehensive report that is called the Post Acute Care Discharge summary (PAC summary). Important elements include: the physician discharge summary, a nursing discharge assessment, updated medication list and a medication administration summary highlighting when last doses were given. We did a lean project to focus on teaching and implementing these changes ex: taught the nurses about only doing a nursing assessment and not doing redundant work of recreating a discharge summary or copying a medication list. We standardized the process by making the preparation and printing of the PAC summary report the job of the office assistant on every medical ward to be done prior to discharge with no other extraneous copying and printing.
Our preproject baseline satisfaction scores with the discharge documentation was 44% and we currently are resurveying the PAC facilities for a 12 week followup satisfaction score. PAC summary was the only documentation sent 0% of the time prior to project, and 1 week after was 62%. Secondary outcomes included decreasing nursing time to complete assessment, which was reduced by 50% from 10 min to 5 min. We conclude that standardizing the post acute care discharge documentation to PAC facilities will increase satisfaction and confidence with the transition of care for patients discharged to these facilities.
To cite this abstract:Shaaban R. Standardization of Discharge Documentation to Post Acute Care (Pac) Facilities R Shaaban, Do, P Owusugriffin, Md Baystate Medical Center. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97686. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/standardization-of-discharge-documentation-to-post-acute-care-pac-facilities-r-shaaban-do-p-owusugriffin-md-baystate-medical-center/. Accessed September 18, 2019.