Opportunities to improve clinical summaries for patients at hospital discharge

Abstract

Our study highlights opportunities to improve clinical summaries for guiding patients' postdischarge care.

Clinical summaries for hospitalised patients: time for higher standards

“…The scores for clinical summaries in this study, on the other hand, ranged from 14.6% to 41.2%, depending on the rater, hospital and domain 8. This performance is quite disappointing.…”

“…In theory, this document should clearly describe the patient's medical conditions, medications, other self-care instructions and next steps for follow-up and recovery. Yet, as shown in this issue of the journal,8 clinical summaries generated by electronic health records (EHRs) fall far short of this goal.…”

“…Sarzynski and colleagues performed a descriptive study in two US hospitals, examining 100 clinical summaries generated through commercially available EHRs 8. In terms of content, they found that clinical summaries generally included administrative information about the hospitalisation, such as the name of the patient and diagnoses; these are the items most easily extracted from the EHR.…”

Problems with discharge summaries produced by electronic health records: why are the vendors not named?

“…The study by Sarzynski and colleagues1 uses rigorous analysis to obtain important insights about the real-time information that patients receive at discharge. It is puzzling that the electronic health records (EHRs) used were not named.…”

Identifying vendors in studies of electronic health records: the editor replies

“…I thank Dr O’Donnell for his letter asking if we did not name the vendors in a study of the electronic health record (EHR)-generated discharge summaries1 as a matter of policy or simply due to an oversight. The vulnerabilities and unintended consequences of health information technologies have appeared as recurring themes in both research papers2–7 and editorials8–10 at BMJ Quality & Safety .…”