Discharge summaries play a key role in the transitional care of patients to nursing facilities, according to a new study published in the Journal of General Internal Medicine by University of Wisconsin researchers, who detailed how the completeness of documentation varied from patient to patient.
The best way to make the process work better is to improve the information in summaries and have them done in a more timely fashion, the report said.
The objective of the work was to examine the relationship among clinical-work processes, provider characteristics, and discharge summary content to identify approaches that promote high-quality discharge documentation.
What researchers discovered was that critical component omissions were common in discharge summaries “and were associated with delayed document creation and less experienced providers.”
Study authors said more research is needed to understand the impact of discharge documentation quality on patient and system outcomes, but it was clear that more work needs to be done on the process of thoroughly documenting transitions to nursing facilities.
The study looked at all (a total of 489) hip fracture and stroke patients discharged to sub-acute care facilities from 2003 to 2005 from a large Midwestern academic medical center. Patients on hospice/comfort care were excluded.
Researchers said they studied 32 expert-recommended components in four categories: patient’s medical course, functional/cognitive ability at discharge, future plan of care, and name/contact information from summaries of sample patients.
The results showed that historical components, like a patient’s medical course, were included more often than components that directly inform the admission orders in the nursing facility, like future plan of care. In the latter category, most summaries included a discharge medication list (99 percent), disposition (90 percent), and instructions for follow-up (91 percent), but less frequently included diet (68 percent), activity instructions (58 percent), therapy orders (56 percent), code status (7 percent), and pending studies (6 percent).