Complete and Timely Discharge Summaries Vital for Enhancing Physician Communication
Experts stress that complete and timely discharge summaries are vital to improve communication among physicians and reduce readmissions.
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Discharge summaries are a key tool to transfer information between the hospitalist and primary
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providers and improving patient care. The Joint Commission has set down the elements that discharge summaries should contain: the reason for hospitalization, significant findings, procedures and treatment provided, patient's discharge condition, patient and family instructions, and the attending physician’s signature and date of service. Importantly, the discharge summary must not bring in new information or conflict with previous documentation substantiated in the patient’s medical record. Despite the crucial role that discharge summaries play, studies have found that they are not given the importance they deserve. A review of literature that appeared in a 2007 issue of the Journal of the American Medical Association noted that discharge summaries were often incomplete and missed important data. The researchers reported that between 66% and 88% of discharge summaries were not sent to the outpatient provider in time for the followup visit and that the outpatient physician did not receive the discharge summary at all for 25% of patients. Other studies have found that lacked quality and were too lengthy. What’s alarming is that these problems persist even today. Hospital Review reported on a study published in the
In January 2016, Becker
Annals of Internal Medicine which
found that less than one third (12 to 33 percent) of primary care physicians surveyed could access their patient's discharge summaries at the time of the patient's first post-discharge visit. This breakdown in communication could mean that primary care physicians lack information about a patient's diagnosis, possible actionable test results, discharge medication reconciliation, required follow-up care and confirmed or pending test or procedure results. Electronic health records (EHRs) have changed the discharge summary scenario in that information can be entered faster in a structured template. Transmission is also much faster. However, the electronic template should be well-designed with prompts for all the required elements. All the important information should be included so that the receiving physician can quickly identify how to respond to the patient’s needs. While entering information into the template, physicians should avoid cutting and pasting, as this could
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lead to errors. The discharge summary should also arrive before the outpatient follow-up visit takes place – studies have found that this reduces the risk of readmission. Experts emphasize the importance of teamwork and cooperation among healthcare providers in creating quality discharge summaries for the smooth transition of care. Many providers choose to outsource medical transcription as this is a proven way to get high quality and timely discharge summaries and other medical reports through EHR integrated medical transcription.
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1-800-670-2809