Optimizing transitions of care (TOCs) has become a clear focus of national health care goals. The discharge (DC) summary is arguably the most important document in the TOC for a hospitalized patient. Ideally, it serves as a summary of the patient's hospital course and discharge diagnoses and serves as a handoff to the next provider(s) of care. Despite its critical importance, however, the DC summary does not have a historical “best‐practice” format, nor are clinicians generally taught how to write such notes. With the advent of documentation in the EHR, new tools are available to assist clinicians in writing comprehensive DC summaries.
To develop a “best‐practice” guideline and corresponding note template for DC summaries used across all services that is comprehensive allows recipients to develop a familiarity with the format and also serves as a guide for those learning how to write a DC summary.
We convened a task force comprised of faculty physicians, midlevel providers, residents, and members of professional billing, hospital coding, HIM, medical informatics, and ITS staff. We reviewed TOC literature, sought expert opinion from TOC researchers, and surveyed skilled nursing facilities to determine the essential components of a DC summary. Each component was then discussed until consensus was achieved on the best practice for that element. The task force developed 2 products, a set of “Best Practices for Writing DC Summaries in the EHR” and a corresponding note template. The guidelines were circulated for approval by the chairs, vice chairs, and residency program directors of each clinical department and received endorsement. The new template was set as the default for nearly all services when choosing “DC summary” as the note type in the EHR. Resident superusers in each program assisted in educating current residents about the new format. The clinical importance of the DC summary and how to write it was taught to the incoming residents and fellows, which started in June 2012 during their EHR training.
By convening a task force and engaging hospital leaders, we were able to successfully implement best‐practice guidelines for writing DC summaries in the EHR. Since mid‐July, we have seen an increase in the number of DC summaries prepared using the best‐practice template. On those services seeing the template by default, 73% of DC summaries are created using the default template. 58% of all DC summaries from our organization are created in this format. A survey of referring providers and skilled nursing facilities is currently under way to assess their satisfaction with the new template. A survey of residents, hospitalists, and midlevel providers is also under way to assess satisfaction with use of the template. Future work will examine the effectiveness of the template in ensuring that elements known to be important for safe TOCs are included in the DC summary.
To cite this abstract:Dean S. The Development of Best Practices for Writing Discharge Summaries in an Ehr. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 145. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/the-development-of-best-practices-for-writing-discharge-summaries-in-an-ehr/. Accessed September 20, 2019.