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Using a multidisciplinary automated discharge summary process to improve information management across the system.
R Crosswhite1, S H Beckham, P Gray
1North Mississippi Medical Center, Tupelo, USA.
The American Journal of Managed Care
|February 6, 1997
Summary
An automated discharge summary system was created to improve patient medical record documentation. This system enhances information management and ensures complete patient records by compiling hospitalization data.
Area of Science:
- Health Informatics
- Medical Documentation
- Healthcare Systems Engineering
Background:
- Deficits in patient medical records, including discharge instructions, follow-up care, medications, and education, necessitate improved documentation processes.
- Current discharge summary processes can be fragmented, leading to incomplete or inaccurate patient information transfer.
Purpose of the Study:
- To develop and implement an automated discharge summary process within a regional integrated managed health system.
- To address identified deficiencies in patient medical record documentation.
Main Methods:
- A multidisciplinary team effort to create an automated system compiling patient data entered during hospitalization.
- Integration of admission medications, patient education, follow-up care, referral activities, diagnoses, and medical events into a comprehensive summary.
Main Results:
- Successful implementation of an automated discharge summary that consolidates critical patient information.
- Enhanced compilation of data from computer pathways used during patient care.
- Generation of structured discharge summaries, orders, instructions, and transfer information.
Conclusions:
- The automated discharge summary process significantly improves information management across the healthcare system.
- This system facilitates the maintenance of complete and thorough patient medical record documentation.
- Enhanced communication and data integrity are key outcomes of the implemented automated process.