Design and Hospitalwide Implementation of a Standardized Discharge Summary in an Electronic Health Record

Abstract

Background The hospital discharge summary is the primary method used to communicate a patient's plan of care to the next provider(s). Despite the existence of regulations and guidelines outlining the optimal content for the discharge summary and its importance in facilitating an effective transition to post-hospital care, incomplete discharge summaries remain a common problem that may contribute to poor post-hospital outcomes. Electronic health records (EHRs) are regularly used as a platform upon which standardization of content and format can be implemented. Objective We describe here the design and hospital-wide implementation of a standardized discharge summary using an EHR. Methods We employed the evidence-based Replicating Effective Programs implementation strategy to guide the development and implementation during this large-scale project. Results Within 18 months, 90% of all hospital discharge summaries were written using the standardized format. Hospital providers found the template helpful and easy to use, and recipient providers perceived an improvement in the quality of discharge summaries compared to those sent from our hospital previously. Conclusions Discharge summaries can be standardized and implemented hospital-wide with both author and recipient provider satisfaction, especially if evidence-based implementation strategies are employed. The use of EHR tools to guide clinicians in writing comprehensive discharge summaries holds promise in improving the existing deficits in communication at transitions of care.

Usability of Electronic Health Record–Generated Discharge Summaries: Heuristic Evaluation

“…A few US organizations have developed templates, outlines, or checklists to standardize their own DSs [ 33 - 35 ], but each of them organizes patient information differently. Moreover, even though a 2009 Transitions of Care Consensus Conference produced a list of items that participants recommended be included in transition records [ 17 ], recent research indicates that EHR-generated discharge summaries in the United States continue to omit data that outpatient providers need to effectively coordinate care [ 27 , 36 - 39 ].…”

Integrated Electronic Discharge Summaries—Experience of a Tertiary Pediatric Institution

“…Other principles useful in the implementation of an eDS are being considered, including the juxtaposition of allowing flexibility while ensuring key criteria are included. 40 If found to improve the quality of eDS, these enhancements could be implemented within eDS across EMRs within Australia.…”

Feasibility of real-time capture of routine clinical data in the electronic health record: a hospital-based, observational service-evaluation study

“…14 Studies to date have demonstrated that the after-visit summary is valued by both patients and primary care physicians. 15 The EHR is now increasingly used to generate discharge summaries for patients who have received inpatient care 16 but its use in the outpatient setting for real-time data capture and development of clinic letters has received little attention and we have identified only a single report from a cancer clinic. 17 As far as we are aware, the potential benefits of such a document in a cardiac outpatient setting have not been examined.…”