Quality of discharge summaries prepared by first year internal medicine residents
1 Department of Medicine, McMaster University, 25 Charlton Ave. East, Suite 708, Hamilton, ON L8P 3B2, Canada
2 Department of Medicine, Internal Medicine Residency Office, McMaster University, HSC-3W10A-C, 1200 Main St. West, Hamilton, ON L8N 3Z5, Canada
3 Department of Medicine, McMaster University, Hamilton, Canada
4 Departments of Medicine, and of Oncology, Juravinski Hospital and Cancer Centre, McMaster University, B3:169D, 711 Concession St, Hamilton, ON L8V 1C3, Canada
5 Departments of Medicine, and of Clinical Epidemiology & Biostatistics, McMaster University, 1200 Main Street West, HSC-3V51B, Hamilton, ON L8N 3Z5, Canada
BMC Medical Education 2012, 12:77 doi:10.1186/1472-6920-12-77Published: 15 August 2012
Patients are particularly susceptible to medical error during transitions from inpatient to outpatient care. We evaluated discharge summaries produced by incoming postgraduate year 1 (PGY-1) internal medicine residents for their completeness, accuracy, and relevance to family physicians.
Consecutive discharge summaries prepared by PGY-1 residents for patients discharged from internal medicine wards were retrospectively evaluated by two independent reviewers for presence and accuracy of essential domains described by the Joint Commission for Hospital Accreditation. Family physicians rated the relevance of a separate sample of discharge summaries on domains that family physicians deemed important in previous studies.
Ninety discharge summaries were assessed for completeness and accuracy. Most items were completely reported with a given item missing in 5% of summaries or fewer, with the exception of the reason for medication changes, which was missing in 15.9% of summaries. Discharge medication lists, medication changes, and the reason for medication changes—when present—were inaccurate in 35.7%, 29.5%, and 37.7% of summaries, respectively. Twenty-one family physicians reviewed 68 discharge summaries. Communication of follow-up plans for further investigations was the most frequently identified area for improvement with 27.7% of summaries rated as insufficient.
This study found that medication details were frequently omitted or inaccurate, and that family physicians identified lack of clarity about follow-up plans regarding further investigations and visits to other consultants as the areas requiring the most improvement. Our findings will aid in the development of educational interventions for residents.