DISCHARGE SUMMARIES FREQUENTLY FAIL TO PROVIDE MEDICAL REASONING THAT IS IMPORTANT FOR CONTINUITY OF CARE

Purpose:    This study focuses on the absence of important data in discharge summaries (DCS) that is frequently needed for medical decision making. 

Methods:

   We performed a retrospective review of the first 75 consecutive DCS after August 1, 2010 by the general internal medicine service of an internal medicine residency at a tertiary hospital in the intermountain west.  Information was manually abstracted regarding the medication resolution (whether medications were identified as being continued, changed, new, or discontinued), mention of medical reasoning or indications for the listed medications, labs that were pending at the time of discharge, and the inclusion of objective clinical findings.  We compared the pending labs reported in the DCS to those in the electronic medical record. 

Results:    The medication list failed to characterize medications as “continued,” “changed,” “new,” or “discontinued” 52% of the time.  Medical reasoning for medication changes was missing 70% of the time in the medication list alone but only 33% when looking through the entire discharge summary.     Only 16% of the labs pending at discharge identified by the EMR were reported in the DCS.  However, 46% of the labs reported in the DCS were missed by the EMR.  The most common pending laboratories (74%) were finalized microbiology cultures.  83% of the laboratory tests missed by the electronic record were INR’s to be drawn following hospital discharge. 

Conclusions:    With a growing emphasis on providing patients with continuity of care and safe transitions of care, the role of clinical documentation is shifting.  While rote historical records of care are important, the need to clearly articulate medical reasoning in documentation is increasing.  Specifically, we observed medication resolution, medication indications, and labs pending at the time of discharge were frequently incomplete or absent.  Overall, there appears to be a frequent failure to provide the information useful for the next steps for patients’ care in the discharge summary.  Our finds suggest that while the EHR may be useful to identify pending results, certain follow-up labs and issues require explicit communication by the clinician, such as when the next INR is due.  Future efforts should leverage existing systems to promote clearer communication of medical reasoning at the time of hospital discharge.    Acknowledgement: Funding provided by National Library of Medicine Training Grant T15LM007124.