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Brief Communications
Method for improving the quality of discharge summaries written by a general medical team P. Russell,1 U. Hewage1 and C. Thompson2 1
Flinders Medical Centre and 2University of Adelaide, Adelaide, South Australia, Australia
Key words electronic medical record, education, documentation, discharge summary. Correspondence Patrick Russell, c/o Clarendon Post Office, Clarendon, SA 5157, Australia. Email: [email protected]
Abstract We developed a writing rubric that assessed the quality of four common errors found in the synopsis of a discharge summary: relevance, accuracy, clarity and presentation (R-A-C-P). We assessed the effect of an intervention that taught the essentials of discharge summary preparation. The intervention reduced the number of inadequate discharge summaries written by medical staff on a busy medical service. Writing the clinical synopsis of a discharge summary is a skill that can be taught quickly.
Received 17 June 2013; accepted 4 November 2013. doi:10.1111/imj.12362
Written hospital discharge summaries are the most widely accepted practice for summarising patient management while in the hospital and communicating this information to other clinicians. There has been increased focus on this transfer of information, which reveals specific deficiencies.1–3 The monitoring of the quality of information in discharge summaries is regarded as a responsibility of the treating consultant who is expected to scrutinise and correct the discharge summary before its distribution. This quality checkpoint can be variably attended (C. Thompson, pers. comm., 2010), leaving little accountability for this important area of information transfer. The quality of the summary’s content is more difficult to appraise reliably than the timeliness of its dispatch, even though the latter is easy to quantify and compare as a key performance indicator. Much of the content and structure of a discharge summary can be generated automatically by an electronic medical record (EMR) system. Despite these improvements, significant deficits remain in the presentation, relevance, accuracy and clarity of the summary, which can potentially adversely affect the quality and safety of patient care.3 The aim of this study was to develop a strategy for assessing and improving the quality of discharge summaries.
Funding: None. Conflict of interest: None.
298
Flinders Medical Centre is a 550-bed teaching hospital located in Adelaide, South Australia. Its five general medical teams include interns who write about 80% of the service’s finalised discharge summaries (C. Thompson, pers. comm., 2010). We developed a quality rubric that allows the educator to fashion a checklist for the important points to be evaluated in a piece of writing, with specific examples of potential errors. The previously mentioned four areas of common error – presentation, relevance, accuracy and clarity – were incorporated in the rubric to grade quality.4–6 This rubric was tested in a pilot audit of 23 discharge summaries with the corresponding case notes for comparison. As a result of this pilot audit, a more detailed rubric (Table 1) was created, which asked the following questions: Presentation: were subheadings used to compartmentalise information, and was the problem list appropriately prioritised? Accuracy: were significant abnormalities reported in the summary corroborated by verified results available in the computer database? Clarity: were all significant findings from that admission included in the discharge summary, or were important details left out? Relevance: was the discussion following the diagnosis or problems in the clinical synopsis directly related to those listed? Were principal and secondary diagnoses listed relevant to the current admission? © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
Brief Communications
Table 1 The rubric Good
Acceptable
Unacceptable
2
1
0
Relevance
Each problem is followed by a discussion which is limited to that particular subheading. Primary and all secondary diagnoses are active problems.
Accuracy
No inaccuracies
Each problem is followed by a discussion which is mostly about that particular problem, but strays a bit into discussing other problems. Secondary diagnoses with confusion with medical history. Not much factual information given, but what is present is generally accurate; minor inaccuracies: for example, ferritin listed as 57 is, in fact 45.
Clarity
All pertinent information included in PIE format: each Problem is discussed in terms of the Investigations, Interventions and End results
All critical information included, although not all secondary diagnoses listed are given a subheading and discussion; for example, peripheral arterial disease (an active disease) listed, but no in-hospital management listed.
Presentation
Problem-lists in the subheadings and arranged in order of importance, starting with the primary diagnosis.
Problems listed as subheadings, but in no particular order.
So much rambling as to render the summary too difficult to understand; almost flight of ideas.
Inaccuracy that compromises future care. For example, troponin is listed as normal for the patient admitted for chest pain, when in fact it is grossly abnormal. It is necessary to read it several times to understand the meaning; crucial information omitted making the document in need of remediation. For example, an abdominal ultrasound to investigate the size of a AAA also discovered splenomegaly not mentioned in the DS; if the primary diagnosis is listed as a symptom (e.g. falls, shortness of breath, collapse, confusion). Complete disregard for subheadings; synopsis given in narrative format.
How we graded the quality of the clinical synopsis of the discharge summary: Our rubric was created with certain characteristics in mind. First, it must be easy to use; second, it must be memorable; and third, it must satisfy the basic requirements we gleaned from a variety of sources, including a literature search, our own experience reading discharge summaries and consultation with colleagues. We learned that discharge summaries at our hospital are inadequate for four basic reasons: the inclusion of irrelevance, important inaccuracies, the difficulty finding the area of interest in post-discharge follow up, and omission of important details. After perusal of several dozen discharge summaries, we developed the following rubric, which covers these four basic areas: relevance, accuracy, clarity and presentation. At first glance, the grading rubric below might seem clumsy and abstruse. Most discussions regarding the quality of a particular discharge summary generally place it in one of three categories: really good; okay (‘it will do’); or substandard and in need of remediation. From this, we decided to give a numerical grade to express what we were qualitatively describing. Three numerical categories to represent these three qualitative distinctions. However, this could be easily modified to a simple pass or fail binary system, especially if the clearest goal of the assessing is to identify those house officers with difficulty communicating.
For each category in this rubric, a score was given: 0 = synopsis requires substantial review from the writer before final distribution of the discharge summary; 1 = meets minimum requirement; and 2 = exemplary standard. A score of 1 or 2 indicated the summary was acceptable for that category. The intervention consisted of a 30-min training session of five interns during their first week of general medicine service. We emphasised the need (i) for a structured problem-based synopsis rather than one that is a freeranging narrative; (ii) for a brief discussion of each problem, P-I-E (list the Problem, then discuss the Investigations and/or Interventions, followed by the End result); (iii) to be clear about the principal diagnosis, listing a pathological diagnosis rather than a symptom or clinical syndrome whenever possible (e.g. ischaemic © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
cardiomyopathy is a better diagnosis to list than congestive heart failure; ‘falls’ is not a pathological diagnosis, but Parkinson disease is); and (4) in the list of secondary diagnoses, to list only the problems relevant to this admission, rather than all past problems that the patient has ever experienced. We used examples of poorly written summaries to demonstrate what to avoid, and well-written ones for inspiration. The hospital charts and corresponding discharge summaries from 80 randomly selected patients admitted during the 12 months before the intervention and from 60 randomly selected patients admitted during the 10 weeks following the intervention were scrutinised. We included any patients whose charts and summaries were written by a general medical team regardless of their possible exposure to the intervention. Cases were 299
Brief Communications
Figure 1 The percentage of summaries deemed acceptable in each of four attributes of randomly selected general medical discharge summaries scored by a single assessor (for the scoring system see Methods and Table 1). The left column of each pair represents assessment of 56 summaries written in 2009 and the right column from assessment of 50 summaries written in 2010 following an intervention. There was a significant improvement in clarity and presentation of summaries in 2010 (P = 0.0001, unpaired t test). ( ), 2009; ( ), 2010.
excluded if: (i) no summary was completed; (ii) patients were admitted to general medicine but discharged from a different service; (iii) patients died during hospitalisation; and (iv) patients were transferred to a different hospital. Each discharge summary was scrutinised by a single assessor who applied the rubric and scoring method while comparing the summary with the corresponding admission and progress notes in the hospital chart. In analysing the differences in category scores between the pre- and post-intervention discharge summaries, non-parametric methods were used, Chi-squared for binary data and Mann–Whitney test for continuous data. Statistical significance was denoted by a P
Brief Communications
Method for improving the quality of discharge summaries written by a general medical team P. Russell,1 U. Hewage1 and C. Thompson2 1
Flinders Medical Centre and 2University of Adelaide, Adelaide, South Australia, Australia
Key words electronic medical record, education, documentation, discharge summary. Correspondence Patrick Russell, c/o Clarendon Post Office, Clarendon, SA 5157, Australia. Email: [email protected]
Abstract We developed a writing rubric that assessed the quality of four common errors found in the synopsis of a discharge summary: relevance, accuracy, clarity and presentation (R-A-C-P). We assessed the effect of an intervention that taught the essentials of discharge summary preparation. The intervention reduced the number of inadequate discharge summaries written by medical staff on a busy medical service. Writing the clinical synopsis of a discharge summary is a skill that can be taught quickly.
Received 17 June 2013; accepted 4 November 2013. doi:10.1111/imj.12362
Written hospital discharge summaries are the most widely accepted practice for summarising patient management while in the hospital and communicating this information to other clinicians. There has been increased focus on this transfer of information, which reveals specific deficiencies.1–3 The monitoring of the quality of information in discharge summaries is regarded as a responsibility of the treating consultant who is expected to scrutinise and correct the discharge summary before its distribution. This quality checkpoint can be variably attended (C. Thompson, pers. comm., 2010), leaving little accountability for this important area of information transfer. The quality of the summary’s content is more difficult to appraise reliably than the timeliness of its dispatch, even though the latter is easy to quantify and compare as a key performance indicator. Much of the content and structure of a discharge summary can be generated automatically by an electronic medical record (EMR) system. Despite these improvements, significant deficits remain in the presentation, relevance, accuracy and clarity of the summary, which can potentially adversely affect the quality and safety of patient care.3 The aim of this study was to develop a strategy for assessing and improving the quality of discharge summaries.
Funding: None. Conflict of interest: None.
298
Flinders Medical Centre is a 550-bed teaching hospital located in Adelaide, South Australia. Its five general medical teams include interns who write about 80% of the service’s finalised discharge summaries (C. Thompson, pers. comm., 2010). We developed a quality rubric that allows the educator to fashion a checklist for the important points to be evaluated in a piece of writing, with specific examples of potential errors. The previously mentioned four areas of common error – presentation, relevance, accuracy and clarity – were incorporated in the rubric to grade quality.4–6 This rubric was tested in a pilot audit of 23 discharge summaries with the corresponding case notes for comparison. As a result of this pilot audit, a more detailed rubric (Table 1) was created, which asked the following questions: Presentation: were subheadings used to compartmentalise information, and was the problem list appropriately prioritised? Accuracy: were significant abnormalities reported in the summary corroborated by verified results available in the computer database? Clarity: were all significant findings from that admission included in the discharge summary, or were important details left out? Relevance: was the discussion following the diagnosis or problems in the clinical synopsis directly related to those listed? Were principal and secondary diagnoses listed relevant to the current admission? © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
Brief Communications
Table 1 The rubric Good
Acceptable
Unacceptable
2
1
0
Relevance
Each problem is followed by a discussion which is limited to that particular subheading. Primary and all secondary diagnoses are active problems.
Accuracy
No inaccuracies
Each problem is followed by a discussion which is mostly about that particular problem, but strays a bit into discussing other problems. Secondary diagnoses with confusion with medical history. Not much factual information given, but what is present is generally accurate; minor inaccuracies: for example, ferritin listed as 57 is, in fact 45.
Clarity
All pertinent information included in PIE format: each Problem is discussed in terms of the Investigations, Interventions and End results
All critical information included, although not all secondary diagnoses listed are given a subheading and discussion; for example, peripheral arterial disease (an active disease) listed, but no in-hospital management listed.
Presentation
Problem-lists in the subheadings and arranged in order of importance, starting with the primary diagnosis.
Problems listed as subheadings, but in no particular order.
So much rambling as to render the summary too difficult to understand; almost flight of ideas.
Inaccuracy that compromises future care. For example, troponin is listed as normal for the patient admitted for chest pain, when in fact it is grossly abnormal. It is necessary to read it several times to understand the meaning; crucial information omitted making the document in need of remediation. For example, an abdominal ultrasound to investigate the size of a AAA also discovered splenomegaly not mentioned in the DS; if the primary diagnosis is listed as a symptom (e.g. falls, shortness of breath, collapse, confusion). Complete disregard for subheadings; synopsis given in narrative format.
How we graded the quality of the clinical synopsis of the discharge summary: Our rubric was created with certain characteristics in mind. First, it must be easy to use; second, it must be memorable; and third, it must satisfy the basic requirements we gleaned from a variety of sources, including a literature search, our own experience reading discharge summaries and consultation with colleagues. We learned that discharge summaries at our hospital are inadequate for four basic reasons: the inclusion of irrelevance, important inaccuracies, the difficulty finding the area of interest in post-discharge follow up, and omission of important details. After perusal of several dozen discharge summaries, we developed the following rubric, which covers these four basic areas: relevance, accuracy, clarity and presentation. At first glance, the grading rubric below might seem clumsy and abstruse. Most discussions regarding the quality of a particular discharge summary generally place it in one of three categories: really good; okay (‘it will do’); or substandard and in need of remediation. From this, we decided to give a numerical grade to express what we were qualitatively describing. Three numerical categories to represent these three qualitative distinctions. However, this could be easily modified to a simple pass or fail binary system, especially if the clearest goal of the assessing is to identify those house officers with difficulty communicating.
For each category in this rubric, a score was given: 0 = synopsis requires substantial review from the writer before final distribution of the discharge summary; 1 = meets minimum requirement; and 2 = exemplary standard. A score of 1 or 2 indicated the summary was acceptable for that category. The intervention consisted of a 30-min training session of five interns during their first week of general medicine service. We emphasised the need (i) for a structured problem-based synopsis rather than one that is a freeranging narrative; (ii) for a brief discussion of each problem, P-I-E (list the Problem, then discuss the Investigations and/or Interventions, followed by the End result); (iii) to be clear about the principal diagnosis, listing a pathological diagnosis rather than a symptom or clinical syndrome whenever possible (e.g. ischaemic © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
cardiomyopathy is a better diagnosis to list than congestive heart failure; ‘falls’ is not a pathological diagnosis, but Parkinson disease is); and (4) in the list of secondary diagnoses, to list only the problems relevant to this admission, rather than all past problems that the patient has ever experienced. We used examples of poorly written summaries to demonstrate what to avoid, and well-written ones for inspiration. The hospital charts and corresponding discharge summaries from 80 randomly selected patients admitted during the 12 months before the intervention and from 60 randomly selected patients admitted during the 10 weeks following the intervention were scrutinised. We included any patients whose charts and summaries were written by a general medical team regardless of their possible exposure to the intervention. Cases were 299
Brief Communications
Figure 1 The percentage of summaries deemed acceptable in each of four attributes of randomly selected general medical discharge summaries scored by a single assessor (for the scoring system see Methods and Table 1). The left column of each pair represents assessment of 56 summaries written in 2009 and the right column from assessment of 50 summaries written in 2010 following an intervention. There was a significant improvement in clarity and presentation of summaries in 2010 (P = 0.0001, unpaired t test). ( ), 2009; ( ), 2010.
excluded if: (i) no summary was completed; (ii) patients were admitted to general medicine but discharged from a different service; (iii) patients died during hospitalisation; and (iv) patients were transferred to a different hospital. Each discharge summary was scrutinised by a single assessor who applied the rubric and scoring method while comparing the summary with the corresponding admission and progress notes in the hospital chart. In analysing the differences in category scores between the pre- and post-intervention discharge summaries, non-parametric methods were used, Chi-squared for binary data and Mann–Whitney test for continuous data. Statistical significance was denoted by a P
