School of Medicine, Griffith University, Parklands Drive, Southport, Qld 4215, Australia; and Corresponding author. Email:
Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia. Email:
Aust Health Rev. 2020 Sep;44(5):699-705. doi: 10.1071/AH19057.
Objective This retrospective study identified and compared the performance of electronic discharge summaries (EDSs) from three hospital in-patient streams (surgical, medical and mental health) with Australian standards. Methods An audit was performed of 120 EDSs extracted from a tertiary hospital. Auditors evaluated each EDS using an adaptation of the Australian Commission on Safety and Quality in Health Care's EDS toolkit. Results EDSs from all in-patient streams were lengthy and most did not include information regarding discharge destination, patient education or recommendations. General Medicine EDSs were most timely, averaging within 1 day of discharge. Conclusions Key areas of improvement remain for improving the timeliness, brevity and completeness of EDSs. Key areas identified for improvement include page length, discharge destination, alerts, patient education and recommendations. Variability in audit results between streams suggests the need for speciality-specific templates, standards and medical officer training. What is known about the topic? The literature suggests that an EDS is timely if it is completed within 2 days of discharge. A complete and brief EDS should also include key details of the care in two (or fewer) pages. What does this paper add? This paper evaluated 120 EDSs, compared them against a standard and stratified the EDSs according to three core clinical in-patient streams that produced them (surgical, medical and mental health). What are the implications for practitioners? Although broad guidelines for timeliness, brevity and completeness have been established for EDSs, each in-patient stream will require different standards. A hospital or health service should have established standards relevant to each in-patient stream. Before commencing a term in any of the three in-patient streams, medical officers who are to generate EDSs should be trained in the required standard. Training should highlight critical elements of a speciality stream to ensure EDS authors are aware of the nuances of the stream in which they are rotating. In addition, general practitioners should liaise with local hospitals to ensure ongoing dialogue and improvement of clinical handover documents.
本回顾性研究旨在根据澳大利亚标准，识别并比较来自三家医院住院患者（外科、内科和精神科）的电子出院小结（EDSs）的性能。
对一家三级医院提取的 120 份 EDS 进行审核。审核员使用澳大利亚安全与质量卫生保健委员会 EDS 工具包的改编版评估每份 EDS。
所有住院患者的 EDS 都很长，且大多数 EDS 都没有包括有关出院去向、患者教育或建议的信息。内科 EDS 最及时，平均在出院后 1 天内完成。
在提高 EDS 的及时性、简洁性和完整性方面仍有改进的关键领域。需要改进的关键领域包括页面长度、出院去向、警报、患者教育和建议。不同患者群体之间的审核结果差异表明需要针对特定专业的模板、标准和医务人员培训。
关于该主题已经了解到什么？文献表明，EDS 如果在出院后 2 天内完成，则被认为是及时的。一个完整且简洁的 EDS 还应包括两页（或更少）内护理的关键细节。
这篇论文增加了什么？本文评估了 120 份 EDS，将其与标准进行了比较，并根据产生 EDS 的三个核心临床住院患者群体（外科、内科和精神科）对 EDS 进行了分层。
对从业者有何影响？尽管已经为 EDS 制定了关于及时性、简洁性和完整性的广泛指南，但每个住院患者群体都将需要不同的标准。医院或医疗服务机构应制定与每个住院患者群体相关的标准。在开始任何三个住院患者群体的任期之前，应培训将要生成 EDS 的医务人员，使其了解他们所在轮转群体的特殊要求。培训应突出该群体的关键要素，以确保 EDS 作者了解他们轮转的群体的细微差别。此外，全科医生应与当地医院保持联系，以确保持续的对话和改善临床交接文件。
