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Assessing Quality and Efficiency of Discharge Summaries

Mountainside Hospital, Montclair, New Jersey

Anca Andrei, MD

Wayne State University, Royal Oak, Michigan

Alvin Fried, MD

Health Information Management and Case Management Departments, Monmouth Medical Center, Long Branch, New Jersey

David Gonzalez, BS

Department of Health Information Management, Monmouth Medical Center, Long Branch,New Jersey

Daniel Shine, MD

New York University Hospitals Center, New York, New York, daniel.shine{at}med.nyu.edu

Discharge summaries are intended to transfer important clinical information from inpatient to outpatient settings and between hospital admissions. The authors created a point scale that rated summaries in 4 key areas and applied the scale at a community teaching hospital over 3 years. Charts of 150 patients were selected equally from those discharged early and late in the academic year. Residents dictated all summaries after July 2003 using a prominently displayed template. Two residents and a senior physician assessed dictation quality. Considerable differences were found among raters, particularly in the evaluation of style. The average of the 3 raters’ scores improved 21%, and dictation length decreased 67% after introduction of the template (P < .001). No relationship was found among service intensity (measured as chart weight), dictation length (measured in lines), and quality. Measured by a comprehensive rating scale, the quality of discharge summaries increased with use of a template while their length decreased.

Key Words: discharge summary • medical record • hospital • quality improvement

American Journal of Medical Quality, Vol. 20, No. 6, 337-343 (2005)
DOI: 10.1177/1062860605281078


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