Many studies show that accurate documentation of discharge summaries and their effective use can reduce hospital readmissions. The Hospital Readmission Reduction Program under the Affordable Care Act (ACA) imposes penalties for unwanted hospital readmissions. As a result, many hospitals are experiencing a loss in Medicare reimbursement and they are improving the quality of care to address the readmission risk.
A new study conducted by the Yale School of Medicine researchers found that discharge summary quality was indeed associated with hospital readmission. According to the lead author of the study, Dr. Leora Horwitz, though discharge summary is actually meant to make outside physicians understand what really happened to the patients during hospitalization, the medical community hasn’t explored its capabilities as a tool for transition from hospital to home. A discharge summary actually does the following and thereby facilitates safer transition.
- Informs outpatient physician regarding the course of hospitalizations
- Identifies pending studies that require follow-up
- Suggests further follow-up testing
- Clarifies changes in medications and treatments post-discharge
It was revealed in this study that patients whose discharge summaries contained useful content or were sent to outside physicians had lower readmission rates.
A 2002 study had found that the risk of re-hospitalization may reduce when patients are assessed just after their discharge by physicians who have received the discharge summary. Discharge summary is an effective way through which the hospital physician can communicate with family doctors. This study explored whether the communication between these physicians via the discharge summary affects patient outcomes.
Improving Discharge Summaries
Another study by the same research team from the Yale School of Medicine led by Horwitz found the quality of discharge summary is insufficient in terms of timeliness, transmission and content even at highest performing hospitals. In order to serve as an effective transitional care tool, the discharge summary requires improvements in all these aspects. Here is how you can improve the discharge summary.
- Include Key Details – Though experts recommend that discharge summaries be kept short for readability, they must include all the key details. According to the Society of Hospital Medicine, the following are the key elements of a discharge summary.
- Problems that result in hospitalization
- Key findings and test results
- Final diagnoses including both primary and secondary
- Brief hospital course
- Patient’s condition at the time of discharge
- Discharge destination
- Medications at discharge
- Follow-up appointments and the management plan proposed
- Problems anticipated and suggested interventions
- Laboratory work and tests pending
- Recommendations of subspecialty consultants
- Documentation of patient education
- Name and phone number of hospital physician records
- Give Importance to Timeliness – Discharge summaries should not be late. If they arrive late, physicians will not know about the discharge of their patients and take charge of their care. Readmission rates won’t be reduced if this is the case.
- Speedy Transmission – Hospitals must ensure the speedy completion of discharge summaries and transmission to outside providers. Hospitals should not only send the summary to the outside provider, but also retain its copy within the hospital. Electronic record system helps to easily accomplish this as the system can record the details faster and share them very quickly.
Even though electronic health records or EHRs are effective for hospitals to manage a large number of discharge summaries, there may be the risk for copy-paste errors. Physicians used to copy and paste details to save their time and effort. However, frequent copy pasting may result in inadvertent errors and this may result in inaccurate discharge summaries. This would make the entire EHR erratic and may even malign your reputation. EMR transcription that involves transcribing physician dictations and populating relevant EMR fields is a more viable option. Consider obtaining help from a professional transcription service to ensure accuracy and timeliness as well as save time and effort.