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Optimizing Discharge Summaries: A Survey of Inpatient Clinician Perspectives and the Path to Standardization
Aaron M Silver1, Leigh Anne Goodman2,3, Michael Burton4
1Oregon Health & Science University, Portland, OR, USA. silveraa@ohsu.edu.
Background:
Over the past two decades, care for complex medical patients has become increasingly fragmented, leading to higher risk of errors during transitions of care. Discharge summaries are crucial for ensuring continuity of care, providing essential information about a patient's hospital stay to both primary care and future inpatient clinicians. However, discharge summaries often suffer from inaccuracies, excessive length, and poor formatting. Standardized templates have shown the potential to improve summary quality and clinician satisfaction but require expert input. The previously published Phase I of our initiative surveyed outpatient clinician perspectives on discharge summaries. To our knowledge, there are no published studies evaluating inpatient clinician uses of, and preferences about, discharge summaries.
Objective:
This study explores inpatient clinicians' preferences as readers of discharge summaries with the goal of enhancing effectiveness and supporting the development of a standardized template to aid all transitions of care.
Design:
We conducted a multisite, multidisciplinary survey of inpatient clinicians, including advanced practice providers and trainees, assessing their use of and preferences for discharge summaries. Qualtrics surveys were distributed electronically and in person across several institutions from January 2022 to June 2022.
Main Measures:
Our primary measure was the ranking of 13 discharge summary components based on importance to the reader.
Key Results:
Our survey response rate was 31%. We found significant agreement between the 5 most and 5 least important components identified by inpatient clinicians. The 5 highest-ranked components were hospital course, discharge diagnoses, medication reconciliation, follow-up, and history of present illness.
Conclusions:
Upon analysis of Phase I and Phase II of our study, there was consensus between discharge summary preferences of inpatient and outpatient clinicians regarding their prioritized components. This consistency may enable institutions to develop templates that reflect these priorities, improving the brevity and clarity of these important communication tools during care transitions.
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Graphic Sheet Documentation:
01:26Guidelines for Nursing Documentation II
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01:21Methods of Documentation III: PIE
01:30Guidelines for Nursing Documentation I
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01:28Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...