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Optimizing the quality of hospital discharge summaries – a systematic review and practical tools a

a

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Markus Unnewehr , Bernhard Schaaf , Rusi Marev , Jason Fitch & Hendrik Friederichs

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a 1

Klinikum Dortmund gGmbH, Respiratory Medicine, Infectious Diseases, Intensive Care Medicine, Dortmund, Germany b 2

Department of Experimental and Clinical Pharmacology, Medical University Pleven, Pleven, Bulgaria c 3

Emergency Department, St George’s Healthcare NHS Trust, London, UK

d 4

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Institute for Education and Student Affairs, Westfälische Wilhelms-Universität Münster, Münster, Germany Published online: 18 Jun 2015.

To cite this article: Markus Unnewehr, Bernhard Schaaf, Rusi Marev, Jason Fitch & Hendrik Friederichs (2015): Optimizing the quality of hospital discharge summaries – a systematic review and practical tools, Postgraduate Medicine To link to this article: http://dx.doi.org/10.1080/00325481.2015.1054256

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http://informahealthcare.com/pgm ISSN: 0032-5481 (print), 1941-9260 (electronic) Postgrad Med, 2015; Early Online: 1–10 DOI: 10.1080/00325481.2015.1054256

CLINICAL FEATURE REVIEW

Optimizing the quality of hospital discharge summaries – a systematic review and practical tools Markus Unnewehr1, Bernhard Schaaf1, Rusi Marev2, Jason Fitch3 & Hendrik Friederichs4 Klinikum Dortmund gGmbH, Respiratory Medicine, Infectious Diseases, Intensive Care Medicine, Dortmund, Germany, 2Department of Experimental and Clinical Pharmacology, Medical University Pleven, Pleven, Bulgaria, 3Emergency Department, St George’s Healthcare NHS Trust, London, UK, and 4 Institute for Education and Student Affairs, Westfälische Wilhelms-Universität Mu€nster, Mu€nster, Germany

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1

Abstract

Keywords:

Objective. Although doctors’ discharge summaries (DS) are important forms of communication between the physicians in patient care, deficits in the quality of DS are common. This review aims to answer the following question: according to the literature, how can the quality of DS be improved by 1) interventions; 2) reviews and guidelines of regulatory bodies; and 3) other practical recommendations? Methods. Systematic review of the literature. Results. The scientific papers on optimizing the quality of DS (n = 234) are heterogeneous and do not allow any meta-analysis. The interventional studies revealed that a structured approach of writing, educational training including feedback and the use of a checklist are effective methods. Guidelines are helpful for outlining the key characteristics of DS. Additionally, the articles in the literature provided practical proposals on improving form, structure, clinical content, treatment recommendations, follow-up plan, medications and changes, addressees, patient data, length, language, dictation, electronic processing and timeliness of DS. Conclusion. The literature review revealed various possibilities for improving the quality of DS.

Discharge summary, medical education, documentation, problem-oriented medical records, process quality

Introduction A high-quality transfer of information from hospital clinicians to the patient’s primary care physician and other treating physicians is essential for maintaining an efficient and safe continuity of treatment and ensuring patient safety, especially by avoiding medication-related errors. This information transfer is particularly important in countries with separate inpatient and outpatient care structures [1]. This communication across the healthcare interface usually takes the form of a written discharge summary (DS), which is transmitted to the physician who continues the treatment. Telephone calls or personal discussions occur only sporadically, which explains why the DS can be regarded as the most important form of communication between doctors in patient care [2]. Hospital doctors working 8 h to 10 h a day spend approximately 3 hours per day on documentation, which is similar to the time spent in direct patient care [3,4]. A clinician generally spends at least one-third of this documentation time, that is, approximately 1 hour per day, writing and correcting DS [5]. Despite this effort, DS often have considerable shortcomings regarding their completeness and quality [6,7], which is especially true for the prescription of medications [8]. Studies have consistently shown that, at most, only 70% of the DS meet the

History Received 5 February 2015 Accepted 20 May 2015 Published online 15 June 2015

requirements established in the guidelines, and up to 40% are incorrect in some way [9-13]. It seems that the medical and scientific communities place little value on this important and time-consuming issue, without adequate education and training. In a recent survey, 36% of the junior doctors reported inadequate training relating to DS, either in medical school or in postgraduate training [14]. This finding is consistent with other studies [15-17].

Objective The aim of the present study is to answer the following three questions by extracting information from the literature: To improve the quality of DS 1. What interventions have been shown to be effective, especially in improving the content of DS? 2. What reviews and guidelines or official statements exist in scientific societies or in regulatory bodies and what is their practical value? 3. What other useful practical recommendations can be found in the literature? To be able to address these questions, a description of the term ‘quality of DS’ is established.

Correspondence: Markus Unnewehr, Klinikum Dortmund gGmbH, Respiratory Medicine, Infectious Diseases, Intensive Care Medicine, Dortmund, Germany. E-mail: [email protected]  2015 Informa UK Ltd.

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Methods Search strategy

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We conducted a systematic literature search in MEDLINE using PubMed, EMBASE, the Cochrane Library, and Google Scholar to include review articles and original papers from 1966 to April 17, 2015. The search terms were ‘DS’, ‘discharge letter’, and ‘discharge note’, each with and without ‘hospital’ and ‘patients’, combined as phrases and single words. The PubMed (Medical Subject Heading) term was ‘Patient DS (Summaries that serve as the primary documents communicating a patient’s care plan to the post-hospital care team. Year introduced: 2014)’. The only database limitation set was ‘human’. We searched the reference lists of reviews and original articles. We also searched for guidelines, monographs, conference papers and other articles on the Internet using a search engine (Google). Inclusion/exclusion criteria and categorization The inclusion criteria were information on the following components of DS: accuracy, form, errors, content (e.g. diagnosis, treatment, and medication), quality improvement, structure, writing, dictating, electronic/computer-assisted processing, transfer and transmission, follow-up plan, timeliness, and general aspects of the DS as a mean of communication. First, the citations of the results were screened by a single investigator (MU). If the title and the abstract referred to one

Figure 1. Literature search.

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of the inclusion criteria, the article was read by two of the authors (MU and HF). If the article did not contain information pertaining to the criteria, it was excluded from the review. The articles in languages that the authors did not understand were translated (n = 6). For better structural clarity, the included articles were categorized as follows (Figure 1): A) content (e.g. accuracy, form, errors, clinical information, and structure); B) processing (e.g. writing, dictating, electronic/computerized, timeliness); and C) communication (e.g. patients’ view, general aspects of the DS as a means of communication). The articles in category ‘A’ were sub-categorized into the following: A1) interventional studies; A2) reviews, guidelines; and A3) others, for example, observational studies and perspective pieces. The data in the interventional studies (A1) were extracted, if possible, into a pre-formatted table (Table 1) that consisted of the name of the first author, the publication year, the methods (question/objective, design, intervention type), and results.

DOI: 10.1080/00325481.2015.1054256

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Table 1. Interventional studies on improving the quality of discharge summaries. Year

Axon

2014 Q: To assess utility of feedback and academic detailing to improve the quality of DS D: n = 96 PG physicians, without control group I: DS quality improvement program (DS template, feedback, academic detailing, DS evaluation instrument) 2009 Q: Improving the quality of DS to reduce medication errors D: Intervention group (n = 52 pt), control group (n = 63 pt) I: Review and feedback of the medication reported in DS using a checklist by clinical pharmacists before pt discharge 2013 Q: Can timeliness and quality of DS be improved by a resident-led multifaceted quality improvement project? D: Prospective study, 123 internal medicine residents I: Educational curriculum, DS template, regular feedback, financial incentive for the residents 2013 Q: Does a ‘psycho-oncological statement’ in the DS enhance patient-physician communication about psychosocial issues? D: Cluster-randomization, n = 1416 pt I: Inclusion of a psycho-oncological statement the DS 1992 Q: To improve DS quality by new DS form D: Observation after intervention I: Re-structuring the DS form and content after discussion with GPs 2011 Q: Does reducing workload increase the quality of DS? D: Random allocation of pt to intervention and control group, evaluation by structured DS assessment tool, n = 61 postgrad. doctors I: workload of 3.5 pt per doctor (intervention group) versus 6.6 pt (control group)

Bergkvist

Bischoff

Book

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Methods Question/objective (Q), design (D), intervention type (I)

First author

Clements

Coit

Dinescu

Key-Solle

2011 Q: Do audit and feedback improve completeness of DS of geriatric pt? D: n = 89 DS, no control group I: Scoring of DS using a checklist, structured feedback of 30 min, re-scoring after 1 year

2010 Q: Does a brief educational intervention improve DS quality? D: Prospective interventional study on first-year pediatric residents (n = 64), scoring key components of DS (n = 477) taught before and after intervention I: Educational group sessions on DS quality Kunz 2007 Q: To examine the impact of one-sentence evidence-based summary in DS for the adherence of GP to recommendations in the DS D: Cluster-randomization, n = 178 GP gave feedback after intervention I: Appending an evidence-based consultant recommendations to DS Lampen-Smith 2012 Q: To evaluate the effect of PPI discharge instructions in the DS D: Cluster-randomization, n= 51 pt, GP record review after intervention I: Additional guideline-based information on PPI review included in DS Mathur 1997 Q: Do specialist recommendations during an audit improve quality of DS? D: n = 86 pt, audit after intervention I: Repeat audit of DS 12 months after implementation of recommendations from a previous audit on asthma in DS Medlock 2011 Q: How to improve communication and timeliness of DS from ICU to wards D: Interventional study I: DS as a transfer note at ICU discharge, automatic assignment of DS responsibility, positive peer pressure by open list of pending DS, decision support, e-mail reminders

Results

Reference

Quality improved from 70% to 82% (p = 0.05) according to score count Increased confidence reported in writing DS

[22]

45% Decrease in medication errors per pt (p = 0.012)

[23]

Timeliness increased from 3.5 days to 0.61 days (p < 0.001) Quality increased (percentage of DS meeting all quality criteria) from 5% to 88% (p < 0.001)

[24]

Written information on psychosocial distress in the DS alone does not affect communication

[25]

Good reception of new form Less paperwork

[26]

DS had more required elements (74% versus 65%, p < 0.001), pt history (65.7% versus 36.1%, p = 0.0005), inpatient narrative (47.1% versus 22.2%, p = 0.003), discharge planning (20.0% versus 5.5%, p = 0.012), continuity of care (24.3% versus 6.9%, p = 0.005). Reducing resident workload can significantly improve DS quality Completeness (91% versus 71%, p < 0.001), admission (93% versus 70%, p < 0.001), length of hospital stay (93% versus 78%, p < 0.001), discharge planning (93% versus 18%, p < 0.02), postdischarge care (83% versus 57%, p < 0.001) improved Score increased by 0.56 points (p = 0.002) Brief educational intervention can improve the quality of DS

[27]

[28]

[29]

Brief evidence summary may improve GPs’ adherence to recommended medication (decrease in GP non-adherence to discharge medication from 29.6% to 18.5% (p = 0.039)) 72% of the GPs were enthusiastic about continuing to receive evidence summaries with DS

[30]

Inclusion of discharge instructions on PPI in DS did not show a beneficial effect in PPI prescribing practice

[31]

Significant improvement of asthma DS documentation quality (e.g. precipitating factors, previous admissions with acute asthma, admission arterial blood gas analysis, admission peak flow rates)

[32]

Multifaceted intervention can be highly effective for improving discharge communication from the ICU 77.9% absolute improvement in completeness, 85.2% more DS written Sustained effect over time

[33]

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Table 1. (Continued) Year

Midlo€v

2008 Q: Can a medication report decrease adverse clinical outcomes? D: Prospective interventional study I: Structured medication report at the time of discharge from the hospital 2012 Q What are the effects of standardized feedback and answering key questions before discharge (‘discharge timeout’)? D: n = 27 PG doctors, post-intervention evaluation of DS by reviews by blinded clinician I: a) Standardized feedback on DS; b) both standardized feedback and verbally answering key questions before discharge 2006 Q: Impact of a DS quality improvement curriculum D: n = 95 medicine interns, measured by 9-item instrument I: a) DS curriculum; b) curriculum plus individualized feedback 2014 Q: Assessing the effect of teaching DS content D: n = 23 DS, assessment by checklist I: Teaching the essentials of DS preparation

Mohta

Myers

Russell

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Methods Question/objective (Q), design (D), intervention type (I)

First author

Stein

Talwalkar

Wolk

Results

Reference

Medication report reduced the adverse clinical events due to medication errors (4.4% versus 8.9%, p = 0.049)

[34]

Only the documentation of tasks to be completed after discharge improved (39% versus 8% absolute improvement, p = 0.05) Methods tested have a limited effect on improving DS

[35]

Large quality improvement of DS after curriculum plus feedback Moderate improvement of the curriculum only

[36]

The intervention reduced the number of inadequate DS Writing the clinical synopsis is a skill that can be taught quickly 2014 Q: Evaluation of a quality improvement model and training Increase of average quality score of DS from program for writing postoperative DS 72.1 to 78.3 after the first intervention (p < 0.0005) D: n = 148 surgical DS, review and score of DS quality and to 81.0 after the second intervention before and after intervention DS quality improved, its length was decreased I: Two briefings of staff on DS content 2012 Q: Does education improve the quality of DS? Quality of hospital DS improved significantly after D: n = 63 DS were reviewed after intervention using a the 2-year educational program 14-item tool, no control group I: Educational program (monthly workshop of 1 h) 2013 Q: Does modest financial incentive accelerate dictating Time from discharge to dictation was decreased by DS? 75.3% (from 7.44 to 1.84 days on average) Pay-for-performance programs may be effective in D: Discharge data measured improving the quality and the efficiency of patient I: $ 50 gift card for fastest medical resident after 1 month care

[37]

[38]

[39]

[40]

Abbreviations: C = Control; D = Design; DS = Discharge summary; GP = General practitioner (family doctor); I = Intervention; ICU = Intensive care unit; PG = Gost graduate; PPI = Proton pump inhibitor; Pt = Patient.

Only those parts of the three quality aspects within the doctors’ direct area of influence were considered in this study. For example, the processing portions of writing, dictating and editing a DS were included, whereas the electronic mailing or other forms of transfer as a means of processing were not considered because they are performed by mailing services and not by the physicians themselves. The transfer of information from the physicians to the patients (discharge information on medication, follow-up, etc.) was not the focus of this study.

Results Literature research Of the articles dealing with the topic of ‘Discharge Summaries’ and fulfilling the inclusion criteria (n = 234), many papers addressed the technical aspects of writing and distributing DS (n = 82, categorized as ‘Processing (B)’). Fewer articles covered general communication issues (n = 41, categorized as ‘Communication (C)’). The majority of the articles (n = 111) focused on the optimization of the content of DS and were thus categorized as A. Within this group, there were 19 articles on studies with some type of intervention, 10 reviews and guidelines, and

82 papers that did not address one of these two topics mentioned (Figure 1). The complete reference list can be obtained from the corresponding author.

Quality of DS The quality of DS can be described and measured by certain indicators. A group of leading US medical societies has developed standards for transition documents (Transition of Care Consensus Conference [TOCCC]) [12,18]. These standards include content standards in which the minimum requirements consist of a diagnosis and problem list, medication list, identification and contact information of the coordinating physician, patient’s cognitive status, and a list of results. Additionally, the information on treatment, prognosis, followup plans and others are mentioned, as well as timeliness and the format of the transition record. The national guidelines and standards of Scotland, Ireland and the UK contain similar lists of essential content in greater details (see Question 2) [19-21]. According to a recent survey by Yemm et al., the key characteristics of a DS are accuracy, completeness, timeliness, and grammar. Regarding the content, medications, medication

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changes and the reason and follow-up plan were considered to be important factors. The discrepancies in these items between the two groups assessed (general practitioners [GP] and junior hospital doctors) underscore the difficulty in establishing a general definition of the optimal ‘quality’ of DS [14].

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Question 1: Interventional studies Regarding question 1, 19 studies were included in this review [22-40]. The analysis of these articles revealed considerable heterogeneity in the types of intervention and research design. Many studies had a qualitative design, which explains why meta-analyses were not feasible and why each paper had to be considered individually. Table 1 gives an overview of the interventional studies and results. Educational and training measures seem to have a positive effect on the quality of DS, namely, brief educational interventions and education programs (workshops) [29,39]. Additionally, common training instruments, such as audit and feedback, are helpful [32]. Structured feedback helped to reduce the length of the hospital stay, among other quality aspects [28]. This outcome is especially true when educational programs, feedback, template and incentives were combined [22,36]. The structural changes of the work environment have an influence on DS quality. A mild incentive increases timeliness remarkably [40]. Reducing the workload, that is, fewer patients per doctors, increased the DS quality. Assisting junior doctors with a DS checklist or template seemed to enhance DS quality as well [22,23]. However, simple clinical instructions to the addressees concerning the treatment plan are not necessarily effective, whereas detailed treatment plans, for example, for medications, are helpful [25,31,34]. The combination of structural and educational changes in a bundle has proven to have an impressive effect, according to a study by Bischoff et al. [24]. Question 2: Guidelines and reviews The review articles focus on general communication issues and content details, as well as computerized processing. Because of the complexity of studies, clear conclusions could not be drawn. Hesselink et al. analyzed the interventions to improve handovers between hospitals and primary care [1]. The reviews of Kripalani et al. and Wilson et al. found deficits in various aspects of DS, for example, timeliness and content [2,9]. Computer-assisted writing and DS transmission seem to be beneficial, according to a review of Motamedi et al. [41]. In clinical practice and postgraduate training, however, these reviews are typically of limited value because they do not contain practical recommendations on how to improve the content of DS. A recently published review by Wimsett et al., however, is helpful in improving the content because it focuses on this theme and presents key components for a high-quality DS [42]. Few guidelines or similar recommendations from official or regulatory bodies exist. The Scottish Intercollegiate Guidelines Network (SIGN) recommendation on discharge

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documents outlines the content and form of a DS, divided into a core discharge document containing information for all of the patients and an extended discharge document for the complex cases. The recommendations given are described in detail and practice-oriented [19]. Similarly, the Irish National Standard for DS and the standard developed by the U.K. Academy of the Medical Royal Colleges describe in detail mandatory content [20,21]. However, the Irish and Scottish standards do not give practical advice on writing the clinical narrative, the portion of the DS that is perceived to be the most challenging. As a helpful contrast, the U.K. standard is web-based supported, which includes a detailed training slide kit [43]. The recommendations by TOCCC outline the necessary information and transmission requirements but do not provide extensive details. Although they can be helpful in defining hospital standards for DS, they are likely to be of less value in clinical practice and postgraduate teaching as guidelines [18]. Question 3: Practical recommendations In addition to the recommendations derived from interventional studies and those presented in reviews and guidelines, the literature analysis revealed practical recommendations. They are presented according to the categorization of three quality aspects of DS introduced above (content, processing and general communication issues). Content Form and structure: Discharge reports usually take the form of structured letters, standardized sheets or tables [44]. To ensure DS legibility, a clear structure and layout are important, which is often provided by the in-house corporate design and computer system [26,45]. Clinical information: According to a recent literature review on the content of DS and other sources as well as the guidelines mentioned above, a DS should contain the following information: addressees, patient data including the time and duration of treatment, diagnoses, procedures, and operations, summary of the patient’s case and the treatment, results of investigations and findings, follow-up plan including treatment recommendations [18,42,46]. However, the precise content of a DS will understandably depend on the medical specialty and the facility. Treatment recommendations and follow-up plan: This section includes the discharging doctor’s recommendations for future treatment and should be formulated as such, avoiding any patronizing wording. The plan should be understandable and practical for the doctor providing additional care [47]. Medications, changes and medication plan: The medication list must be complete and should include the exact dosages and times [7,10,48]. All of the medication changes and the reasons must be detailed, ideally in the form of a medication report, in addition to the DS, because this decreases the incidence of adverse clinical events [34]. However, the implementation of a medication report is difficult because it requires responsible physicians who understand the

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importance of reliable and efficient transfer of information, which is not always the case [49]. Addressees and patient data: Modern electronic methods of issuing DS often insert this information automatically [50]. The addressees’ names must be complete and correct. In addition to the primary care physician, these usually include other specialists and the referring physicians [18]. Length: A DS should always be as short as possible [38,51]. A concise style and good structure save time and improve readability [44]. By optimizing the language used, even long hospital stays can be summarized in less than half a page of typed text, without sacrificing important information. Interestingly, the quality of a DS increases as the length of the DS decreases [38]. Language and wording: As a technical note among physicians, there are no requirements for beautiful choice of language in a DS. The correct and clear use of language improves the length and the content of the summary [45]. This type of DS includes eliminating redundancies and superfluous words, avoiding vague and meaningless phrases, using correct grammar, and avoiding unknown abbreviations and jargon. All of these recommendations will improve patient safety as well as readability [52]. Furthermore, concise, accurate and appropriate wording is efficient because it helps to avoid time-consuming clarification inquiries. Improving the wording also helps to improve clarity of thinking, thereby increasing the writer’s interest and motivation [53]. The characteristics of the linguistic expression and the cultural background should be considered in the comparison or translation of DS in different languages [54]. Processing Dictating and typing: Whenever the work conditions permit, DS should be dictated rather than typed by the physician because this process is significantly faster and more efficient [41,55]. The overall quality of a dictated letter tends to be better. Combined with electronic compilation, dictation is the most efficient mode of writing [55-57]. Speech recognition systems simplify the task and are increasingly popular. Whenever possible, DS should not be handwritten to ensure legibility [45]. A recent audit showed that only 57% of the DS received in an urban GP practice were typed and that 13% had legibility problems [11]. Electronic processing: Currently, the majority of DS is written with the assistance of computer systems. In the literature, the term ‘electronic discharge letter’ is not used consistently because it describes various degrees of computer assistance [45]. According to the literature, electronic assistance seems to improve the efficiency, timeliness and quality of DS, which is especially true when it is combined with electronic dictating [50,55,58]. However, the implementation of electronic DS can be difficult because it requires compliance and training [59,60]. One or two DS: To ensure timeliness, the patient must be discharged from the hospital with a discharge document. However, the results of investigations and the approval of senior doctors are occasionally pending, which explains why the creation of two different documents is still in practice

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[45]. For example, the Scottish SIGN discharge document standard differs between a ‘core discharge document’ for all of the patients and an ‘extended discharge document’ for the complex cases [19]. Electronic DS usually focus on one single document [50,61]. Timeliness: In most countries, the patient sees his primary care physician on the same day or within days of discharge from the hospital. At this point, the decisions about additional treatment are made. To facilitate this process, the patient or his doctor should have received a DS that details all of the necessary information concerning the patient’s hospital visit [62]. Studies have suggested that timely arrival is important because delays in sending the summary lead to a poorer quality of care [63,64]. According to recent research, a timely DS can reduce hospital readmission, among other factors [64]. The delayed creation of DS is associated with a higher error rate [47]. Since 2010, for UK National Health Service healthcare trusts, it is mandatory to send a standardized DS within 24 h after discharge from the hospital to the GP (‘Clinical Data Standards Assurance Programme’) [43]. Structured writing approach and checklist: Even for experienced clinicians, writing a DS can be challenging. Based on the literature, using a structured approach and a checklist can be recommended [33,46]. Lenert et al. proposed a structure similar to the ‘SOAP’ (subjective – objective – assessment – plan) system for progress notes [65]. Similarly, the Australian Melbourne Children’s Hospital recommendations contain helpful practical content, including a checklist, to be used in training [66]. By following the sections of a checklist step by step (for an example, see Table 2), the content and structural aspects can be incorporated and a standardized form of reporting can be obtained, errors in the content of the DS can be reduced, and its quality can be improved [39,67,68]. General communication aspects Education and training: The educational aspect of dictation is particularly important in postgraduate training. Having to prepare a short oral presentation of the patient case provides training in structured medical thinking and presentation skills. Because these skills must be learned, young doctors often perceive the writing of DS as a difficult task. Additionally, the lack of systematic teaching often leads to an initially unstructured, inefficient and occasionally incorrect ‘learningby-doing’ [10,33,69]. Instead, educational training programs, the use of checklists and other structured approaches, as well as audit and feedback, are helpful. However, a single training program during medical school seems to be of limited effect; repetitive teachings and feedbacks during postgraduate education seem to be more favorable [16]. These recommendations are also consistent with the results reported in interventional studies (Table 1). Quality assurance: Writing the DS, especially dictating it, forces the doctor to remember and think through the patient’s case. Quite often, this process enables the clarification of context or the provision of missing information. Approximately 90% of DS are written by doctors in their first and second year of postgraduate training, as a UK study by Dornan at al. has shown [70]. To improve quality, the DS should be

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Table 2. Discharge summary checklist. If all questions are answered “yes,” the letter can be forwarded to the senior physician for proofreading. Yes/No? Form Are the patient’s data, addressees, and signatures complete and correct? Diagnoses Are all of the diagnoses complete, up-to-date, and accurate (including stages and classifications)? Is the list of diagnoses structured reasonably and clear? Is the list free from irrelevant content? Summary

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Are the key findings, diagnostic ideas, decisions, and uncertainties presented logically? Was the cause of the chief complaint or the patient’s presentation addressed and discussed? Is the summary not longer than 1/2 to 1 typed page? Were superfluous details and redundancies deleted? Treatment recommendation Are all of the recommendations of the pharmacological or other treatments mentioned? Language Is the text readable and understandable without redundant words, complicated sentences, abbreviations and slang? Is the discharge summary free from spelling and grammatical errors? Content Does the summary contain all of the relevant findings and results in a clear form?

corrected and validated by a senior physician after a junior doctor has written it [28,29]. This procedure is required by the guidelines [19-21]. Patients’ outcome, safety, and perspective: Of considerable importance, only sporadically, the patients’ outcome and safety are endpoints of studies on DS [71]. A recent Cochrane review suggested that discharge planning could be favorable for the patients (reduced length of hospital stay and readmission rates) but with uncertain effect on health outcomes, mortality and costs [72]. However, there are no such reviews on DS. A timely DS seems to be associated with a reduction in hospital readmission as an indirect marker of patients’ health outcome [64,73]. Improving the quality of DS helps to avoid errors and increase the quality of care, which is especially important with regard to medication errors [23]. Providing patients with a copy of their DS has been demonstrated to be valuable [74-76]. Medico-legal aspects: If the DS is incorrect, unclear, incomplete or delayed, its author could be held liable for any harm to the patient. Additionally, doctors may rely on the accuracy of the DS if there is subsequent litigation [63].

Discussion The overall aim of this review was to find information in the literature on how to improve the quality of DS. The term ‘quality’ is difficult to use because there are no defined criteria for the quality of DS. The search and analysis of the literature could have been influenced by a selection bias by the authors. We minimized this effect by defining a clear search strategy using broad search terms (e.g. ‘DS’ and ‘hospital’) for the first screening and specified keywords as the inclusion criteria. The subject ‘DS’ is often addressed by ‘unofficial’ in-house recommendations, papers and presentations. Therefore, some information may have been ‘hidden’, for example, in downloaded sections of websites or in paper versions, and may have been missed despite our thorough search. The topic of medical documentation, especially DS, has broad overlaps within the fields of clinical medicine,

communication, documentation, language, and technical, that is, electronic data processing, aspects. Therefore, any scientific approach to DS using common methods, such as controlled trials, might not be feasible, which explains why the literature contains many perspectives and why there is only a limited amount of interventional studies that are heterogeneous in design. However, our review showed that several important aspects of DS could be derived from the literature. To be of any use, the quality improvements of DS must ultimately result in the improvement of patients’ health. Only few studies address the patients’ outcome as endpoints [12,64]. The studies on medication errors in DS were not the focus of this review. The effects of the guidelines and the TOCCC recommendations must be assessed. However, because of the broad and overlapping fields that DS covers with confounding factors, distinct results from studies will be difficult to obtain. Clinical experience, however, shows that low-quality DS, especially errors in medication and treatment recommendations, can cause severe adverse events and thus influence the patients’ outcome. In our experience, in various hospitals throughout the world, the recommendations derived from the literature and listed in the results section are, for the most part, in accordance with daily clinical practice. Several authors and the SIGN favor the creation of two DS (e.g. handwritten and electronic, core document and extended document) [19,45]. However, we recommend creating one single document before the scheduled discharge and labeling it ‘Preliminary DS’ before handing it to the patient. This process is less labor-intensive because the writing physician may recall more details of the case [47]. Pending results can be added later in the same document before the complete DS is transmitted to the GP after being approved by senior doctors [6]. Especially for doctors in training, the intellectually most challenging section of the DS is the clinical summary or narrative or synopsis considering the limited clinical experience and presentation skills of younger doctors, as a study by Kind et al. has shown [47]. Unfortunately, there are limited recommendations in the literature regarding how to write this portion of the DS [44,65]. From our experience, we confirm

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that it is good practice to start the narrative with a short sentence stating the chief complaint or the reason for the patient’s hospital admission, for example, “The patient was admitted because of acute dyspnea.” For clarity, a detailed medical history should only be included in the section “test results and findings.” The narrative essentially summarizes and evaluates the landmark findings that led to the diagnosis. It also discusses any special treatment decisions and ambiguities. It is not, however, necessary to list non-relevant findings and treatment details. Finally, it is necessary to document to what extent the findings explain the symptoms or the reason for hospitalization. It is troublesome and can be dangerous for the patient if the specialists do not give a clarifying assessment of difficult or diffuse symptoms. From our experience, improving the style and wording of DS is important not only for linguistic or syntactical reasons but also as a valuable educational tool. The German philologist and philosopher Friedrich Nietzsche noted that “To improve the style – this means to improve the thought – and nothing more” [53]. For example, correcting the diagnosis listing of a lung cancer case by adding the concise staging forces the writer to re-think the entire diagnostic and staging process. Any discussions of wording issues of DS thus ultimately comprise discussions of the patient’s clinical case and teaching sessions. Documentation requirements in clinical medicine are considerable and consume as much time as direct patient care [4,5]. It is logical to include optimization strategies and efficient writing of DS to reduce documentation efforts. Optimizing the DS focuses on the reader’s perspective, who demands an understandable document above all [45]. The time pressure in hospitals, outpatient clinics and GP practices does not allow doctors to read lengthy DS that are not immediately understandable [45]. Additionally, primary care physicians have different expectations of DS compared to hospital doctors [14]. The considerable discrepancy between the amount of time spent writing DS and the little value placed on this subject in postgraduate education, science and medical discussion can be explained by a general lack of interest in DS. In a trial for implementing a medical report in DS, Eriksson et al. reported the disturbing ignorance of doctors regarding this important theme [49]. The reasons for this lack of interest are a resentment against any documentation issues, lack of interest in linguistic matters, and most likely, a lack of training of younger physicians [15]. This problem is not limited to local or situational circumstances. As the study by Al-Damluji et al. noted, the low quality of DS seems to be independent of the performance level, teaching status, and geographical and other characteristics of hospitals [12]. To improve patient care and safety as well as working conditions for doctors, the current deficits in teaching, discussion and research on this topic must be addressed [13]. Improving the systematic teaching of how to write DS is within the responsibility of the medical schools, specialty training institutions and professional bodies [32,36]. Although interesting and innovative educational ideas, for example, a ‘pay for performance’ system investigated by Wolk et al. or a combination of training, feedback, template

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and incentive assessed by Bischoff et al. should be appreciated and applied in clinical practice, the focus of postgraduate training seems to be simple educational sessions and workshops combined with feedback [24,40]. It is hardly understandable and unsettling why only few official and regulatory bodies worldwide seem to place value on the DS subject, which is reflected by a minimal amount of guidelines and scientific discussions. The guidelines of Ireland, Scotland and England, especially the UK Health and Social Care Information Centre guidance, are valuable in clinical practice and far ahead of countries, such as Germany. The draft version of a national catalogue of learning objectives for medical studies in Germany now includes ‘writing or dictating DS’ as a core objective, which is only a small step in the right direction [77].

Conclusion The literature review underscores that there is a variety of possibilities for improving the quality of DS. Interventional studies revealed that a structured approach of writing, specialized educational training including audit and feedback, and the use of a checklist are effective methods. The few existing guidelines are helpful by outlining the key characteristics on content and the processing of DS. Other fields of quality improvement addressed by scientific papers are form, structure, clinical content, treatment recommendation, follow-up plan, medications and changes, addressees, patient data, length, language, dictation, electronic processing, timeliness, quality assurance, patients’ perspective and medico-legal aspects.

Declaration of interest The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

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DOI: 10.1080/00325481.2015.1054256

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