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

2015; Taylor & Francis; Volume: 127; Issue: 6 Linguagem: Inglês

10.1080/00325481.2015.1054256

1941-9260

Markus Unnewehr, Bernhard Schaaf, R Marev, Jason Fitch, Hendrik Friederichs,

Electronic Health Records Systems

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.