A discharge summary is a valuable document that gives an overview of a patient’s hospitalization from admission through discharge. It helps us know about the continuity of care, ensures safe patient transition from the hospital/nursing institution to the home, and improved patient communication and education. Each time a patient is released from a hospital, a discharge summary is generated. It contains vital patient details such as the diagnosis, co-morbidities, procedures provided, complications and future treatment plan after an inpatient hospital stay. Given the importance of discharge summaries, these have to be accurate and complete and this can be ensured with the support of efficient EHR integrated medical transcription services. Physicians/hospitals utilizing these medical transcription services benefit not only from good discharge summaries, but also valuable savings in terms of time and effort.
Significance of Discharge Summaries often Overlooked
According to two Yale School of Medicine studies, quick delivery of a detailed discharge summary from the hospital to the patient’s doctor can help avoid readmission and aid in the patient’s recovery. Discharge summaries help the doctor know all details regarding the patient’s health condition. These are also used by insurance companies to determine billing. When the patient is discharged from the hospital, the doctor who is going to provide the follow-up care should be given an accurate and complete discharge summary. According to Steven Wolfson, a New Haven area cardiologist, the transition from the hospital to home is a critical time in a patient’s life because the information flow is very significant but unfortunately is very often poor.
According Dr. Leora Horwitz, adjunct professor at Yale School of Medicine and director of the Centre for Healthcare Innovation and Delivery Science at New York University Langone Medical Centre, discharge summaries are more often used a tool for billing purposes and not fully utilized as a tool for transitions.
Horwitz’s team analyzed around 1500 discharge summaries from 46 hospitals. They highlighted the fact that discharge summaries should be sent to the primary doctor in a timely manner so that they become useful for them. The team also conducted a second study using the same data, and found that the quality of summaries was directly related to the risk of readmission.
The effectiveness and quality of care for patients largely depends on the communication between physicians both in secondary and primary care. Discharge summaries should ideally be completed prior to discharging patients from the hospital and copies should be kept in the patient’s file, given to the patient as well as forwarded to the concerned general practitioners.
Components of a Good Discharge Summary
- Admission and discharge dates
- Names of physicians involved in the patient’s care
- Initial and final diagnoses
- Key laboratory and diagnostic data
- A list of operations and medical procedures performed
- A chronological narrative of the patient’s progress from admission through discharge
- Medications of the patient at the time of discharge
- Patient’s condition at the time of discharge
- Post-discharge instructions and plans
Physician and hospital documentation can be streamlined and completed in a timely manner with the help of a reliable medical transcription company. Medical transcriptionists now play a more important role as editors ensuring higher quality and accuracy to discharge summaries and other medical reports through EHR integrated medical transcription. Accurate and complete discharge summaries will have a positive impact on patient care and reduce the costs incurred due to increased rates of readmission.