Focus on the Discharge SummaryNeal Axon, MD

Medical University of South Carolina

Aging Q3: Hospital Care and Transitions

Funding provided by D.W. Reynolds Foundation

Hospital Care and Transitions TeamWilliam Moran, MDKim Davis, MDRogers Kyle, MDFletcher Penney, MDPaul Rousseau, MDLauren Angotti, MDNeal Axon, MDAmy Thompson, PharmDKaren Lucas, RNJustin MarsdenPatty Iverson

Overall Program Learning Objectives1. Appreciate the importance of timely,

comprehensive, concise discharge summaries as a tool to help prevent adverse events.

2. Know local and national policies with respect to timing of discharge summary completion.

3. Know the elements which constitute a comprehensive discharge summary.

4. Know format and style to help make summaries concise and readable.

5. Construct a discharge summary which reflects standardized quality criteria.

6. Critique a discharge summary according to standardized assessment criteria.

JCAHO Requirements for Discharge Summaries

“A concise discharge summary providing information to other caregivers and facilitating continuity of care includes the following:

• Reason for hospitalization• Significant findings• Procedures performed• Care, treatment, and services provided• Patient's condition at discharge• Discharge Information provided to the patient and family, as

appropriate, toinclude:

• Medications• Diet• Physical Activity• Follow-up care”

****Discharge information must be documented or dictated and authenticated within 30 days post discharge. *****

MUSC Discharge Summary RequirementsALL discharge summaries must be dictated by

a responsible provider within 48 hours.

All discharge summaries must be signed by an Attending provider within 14 days.

Standard elements for discharge summaries approved by the Medical Executive committee (Spring 2010)

Common Discharge Summary DeficienciesOnly 12-33% of discharge summaries available

at first follow up

Many summaries leave out important information14% omit hospital course17% omit responsible inpatient provider

21% omit discharge medications

38% omit key test results65% omit pending tests at discharge

91% omit patient counseling/instructions

MUSC Discharge SummariesItems scored as either present or absent

Item Percent Compete

Referring Provider 89%

Past History 98%

Condition at Discharge 58%

Patient Instructions 50%

Tests Pending at Discharge

17%

MUSC Discharge SummariesItems Requiring Editing for Content

Item Percent Omitted

Percent with too much or not enough detail

Percent with appropriate amount of detail

HPI 0% 5% 95%

Physical Exam

16% 46% 37%

Ancillary Test Results

13% 13% 74%

Hospital Course

2% 35% 63%

MUSC Discharge SummariesItems Requiring Additional Information

Item Percent Omitted

Percent with intermediate score

Percent with top score

Allergies 12% 23% 65%

Discharge medications

4% 68% 28%

Specific Follow-up Plans

5% 60% 35%

Can Discharge Summaries Improve?Single center study, 59 Medical InternsResidents receiving feedback were

significantly more likely to include:Key discharge summary componentsHeadingsProceduresPrimary diagnoses

Residents had higher ratings for:Overall readabilityOverall lengthHPIHospital course

Myers JS. Academic Medicine, Vol. 81, No. 10 / October 2006 Supplement

Key AttributesTimely

Clear, concise, complete

Forward lookingMedications reconciledPending tests enumeratedSpecific follow up plans noted

How will it all work?

Individual Feedback

Team Feedback (Inpatient setting)

Critiquing discharge summariesMorning report (Inpatient Setting)Outpatient setting

Individual FeedbackWho: All InternsWhat: Individualized feedback on discharge

summariesReview specific discharge summaries for

standardized criteriaSuggestions for improvement

When: December 9th, 12:00 pmWhere: 300 CSB

Team FeedbackWho: Inpatient General Medicine Teams

What: Recent discharge summaries reviewed according to standard criteria

When: Approximately once per week

Where: During or after team rounds

Morning Report DetailingWho: All residents and interns attending

morning report

What: Review (de-identified) discharge summaries illustrating key teaching points

Where: 300 CSB

When: 8:30 AM Mondays/Fridays

Critique Discharge SummariesWho: All residents

What: Review discharge summaries of recently discharged patients. 4 key attributes Timely Concise Medication Reconciliation Pending Tests

When: Whenever a patient recently discharged patient is seen in follow up

Where: UIM Continuity Clinic

Blue Sheet: PCT TasksPCT TASKS:

1. Ask “Have you been hospitalized in the past 3 months?”

YES

NO

2. If yes to #1, Ask “Were you hospitalized at MUSC?”

Yes

No

3. If yes, please pull the MUSC discharge summary for the resident physician from Practice Partner OR provide a copy of any outside hospital summary if available.

Blue Sheet: Resident TasksRESIDENT TASKS

1. Review Discharge Summary, if available answering the questions below.

A. Was the discharge summary concise? Not at all concise, overly wordy

Somewhat concise, with a few extraneous detailsVery concise, without any extraneous details

A. Was the discharge medication list complete with evidence of reconciliation with outpatient medications?

Yes

No

A. Were pending test results and/or recommended follow up tests noted?

Yes

No

1. Discuss Discharge Summary with Outpatient Attending.

1. Complete Practice Partner Template.

1. Place Blue Sheet in AQ3 Bin in the Resident Charting area.

Outpatient Detailing: Attending TipsEmphasize the 4 key points!!!!

1. Timely: If the summary is not yet dictated at the time of follow up, then ITS NOT TIMELY!

2. Concise: Point out sections that are not concisea. HPI unchanged from H&P, still in present tenseb. Physical Exam with more than 2 systems

without positive findings listedc. Hospital Course with unnecessary details, or

poorly organized without discrete sections for each problem addressed

3. Medications Reconciled:a. Admit/discharge lists OR annotated

discharge meds list4. Pending Tests Results Listed

Questions?

Inpatient Detailing StepsBriefly review and discuss Discharge Summary

when approached by an AQ3-HCT ACOVE member before rounds.

Use the provided yellow sheet, discharge summary, and grading sheet to facilitate a team discussion about high quality discharge summaries

Write your name and the names of all the interns/residents who have been detailed on the yellow sheet

Drop the yellow sheet in the bin on 8E OR fill in the detailing posters on 8E or in the resident library

Properly discard the summary/grading sheets

Item Section Value

Scoring Scale Multiplier

Points

Comments

Referring Provider

20% of Total

0 1 5History of Present Illness 0 1 2 2.5Pertinent Past History 0 1 2.5Allergies

0 1 21.2

5Physical Exam

0 1 21.2

5Ancillary Test Results

0 1 21.2

5Hospital Course 30% of

Total0 1 2 3 10

Discharge Diagnoses

50% of Total

0 1 2 5 Medications 0 1 2 3 5Discharge Condition 0 1 5Patient Discharge Instructions

0 1 5

Tests Pending at Discharge

0 1 5

Follow Up 0 1 2 5Total Score (out of 100 points)

Letter Grade

ID _____________Date of Review _____________

Initials of Reviewer _____________

“OK, but what do I actually say about Discharge Summaries?”

Point out the medical literature: Discharge summaries have room for improvement (Yellow sheet)

Emphasize the key attributes of a high quality discharge summary (Yellow sheet)

Point out specific deficiencies on the graded discharge summary, and suggest how to do better

Encourage the residents/interns to use a template (Pocket Card) each and every time to improve their performance

Questions?