Assessing the Quality of Electronic Discharge Summaries: A Cross-Sectional Study Using the Validated Spanish Version...

Hospital discharge represents a critical moment in the inpatient care process, and its documentation, known as the discharge summary, plays a fundamental role. Incomplete discharge summaries may lead to hospital readmissions, adverse events, poor understanding of treatment and disease, patient and family dissatisfaction, lack of follow-up, and discontinuity of care. In 2017, Hospital Municipal de Agudos "Dr. Leónidas Lucero" (Bahía Blanca, Buenos Aires Province, Argentina) implemented an electronic health record system. Although substantial experience has been gained in its use, the quality of discharge summaries has never been systematically evaluated.

To assess the quality of discharge summaries produced between July 2023 and June 2024 by the Internal Medicine Inpatient Service using the Physician Documentation Quality Instrument-9 Spanish Version (PDQI-9 SV).

An observational, descriptive, cross-sectional study was conducted. The PDQI-9 SV consists of nine items (up-to-date, accurate, thorough, useful, organized, comprehensible, concise, synthesized, and internally consistent), each scored on a 5-point Likert scale. Prior to data collection, an instrument adaptation process and reviewer training were carried out. The assessment was done by two trained physician reviewers.

A total of 135 discharge summaries were analyzed. The mean overall quality score was 34.77 (standard deviation [SD] = 4.17). The highest-scoring domains were accuracy (mean = 4.32; SD = 0.43), completeness (mean = 4.02; SD = 0.85), and internal consistency (mean = 4.01; SD = 0.65). The lowest-scoring domain was conciseness (mean = 3.28; SD = 0.90). No statistically significant differences were observed according to physician seniority (p = 0.757) or day of the week (p = 0.809). Interrater agreement was moderate (intraclass correlation coefficient = 0.63; 95% confidence interval: 0.45-0.75).

Overall discharge summary quality was good, with strengths in accuracy, completeness, and internal consistency. The absence of differences according to physician seniority or day of completion suggests homogeneous documentation practices. Lower scores in conciseness highlight a clear opportunity for targeted educational interventions.