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Design of an orthopaedic-specific discharge summary
Christine Soong1,2, Bochra Kurabi3, Kathleen Exconde4
1Division of General Internal Medicine, Mount Sinai Hospital, 600 University Avenue, Room 428, Toronto, ON, M5G 1X5, Canada. christine.soong@utoronto.ca.
Background:
Patients undergoing orthopaedic procedures experience major changes in function and daily routines upon their return home. Discharge summaries are an important communication tool that may play a role in optimizing a safe transition from hospital. Current care gaps and key elements of an ideal discharge summary specific for orthopaedic population are unknown. We sought to identify the challenges of current orthopaedic discharge summaries and to determine key elements of an ideal document.
Methods:
Qualitative study survey using semi-structured interviews with a sample of 17 patients and clinicians representing diverse professions, backgrounds, and practice settings. We used the constant comparative method of qualitative analysis to define the experiences and perceptions of quality gaps and strategies to improve orthopaedic-specific discharge summaries.
Results:
We identified 3 major themes describing factors perceived to be limiting the quality of current discharge summaries: 1) physician-centric documentation and the absence of a comprehensive, inter-professional perspective; 2) access to resources and health informatics; and 3) process variations in document creation and dissemination.
Conclusions:
Clinicians and patients identified several factors limiting the quality of discharge summaries among orthopaedic inpatients. Incorporating these elements could improve hospital transitions.
Related Concept Videos
01:31Discharge Summary Forms
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
01:17Flow Sheet
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
01:18Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
01:28Formats for Nursing Documentation
Nursing Assessment Form:
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01:26Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:06Legal Guidelines for Documentation