Abstract
Objective Succinct and timely discharge summaries (DSs) facilitate ongoing care for patients
discharged from acute care settings. Many institutions have introduced electronic
DS (eDS) templates to improve quality and timeliness of clinical correspondence. However,
significant intrahospital and intraunit variability and application exists. A review
of the literature and guidelines revealed 13 key elements that should be included
in a best practice DS. This was compared against our pediatric institution's eDS template—housed
within an integrated electronic medical record (EMR) and used across most inpatient
hospital units.
Methods Uptake and adherence to the suggested key elements was measured by comparing all
DSs for long stay inpatients (> 21-day admission) during the first year of the EMR
eDS template's usage (May 2016–April 2017).
Results A total of 472 DSs were evaluated. Six of 13 key elements were completed in > 98.0%
of DSs. Conversely, only < 5.0% included allergies or adverse reaction data, and < 11.0%
included ceased medications or pending laboratory results. Inclusion of procedure
information and pending laboratory results significantly improved with time (p = 0.05 and p < 0.04, respectively), likely as doctors became more familiar with EMR and autopopulation
functions. Inclusion of “discharge diagnosis” differed significantly between medical
(n = 406/472; 99.0%) and surgical (n = 32/472; 51.6%) DSs.
Conclusion Uptake and adherence to an EMR eDS template designed to meet best practice guidelines
in a pediatric institution was strong, although significant improvements in specific
data elements are needed. Strategies can include a modification of existing eDS templates
and junior medical staff education around best practice.
Keywords
best practice - discharge summaries - electronic medical records - template
