Lakhaney Divya, Banker Sumeet L
Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
Department of Pediatrics, Columbia University Irving Medical Center, New York, New York.
Hosp Pediatr. 2020 Nov;10(11):949-954. doi: 10.1542/hpeds.2020-0148.
The need for high-quality discharge summaries is critical to ensure safe transitions of care. Deficits may lead to lapses in communication and poor outcomes. In this study, we sought to characterize the completeness, accuracy, and quality of pediatric discharge summaries.
A retrospective chart review of 200 discharge summaries of patients discharged from the general pediatrics service from July 2016 to October 2017 was conducted. These summaries were audited for 7 elements: admission date, discharge date, discharge diagnosis, medications, immunizations, pending laboratory tests, and follow-up appointments. Accuracy was verified through chart review. Quality of hospital course and patient instructions was evaluated by using a modified validated discharge summary evaluation tool. Additional data collected included medical complexity of the patient and the number of authors. Analysis of variance, χ tests, and Pearson correlations were used to analyze data.
Discharge diagnosis, medications, and follow-up appointments had the lowest rates of completion and accuracy. The quality of the hospital course and patient instructions was variable, with no statistical significance seen in quality scores on the basis of the number of authors or medical complexity. There were more inaccuracies in discharge medications for patients with baseline chronic conditions than those without chronic conditions (63% vs 35%; < .001).
Content and quality of discharge summary documentation are inconsistent and have implications for patient outcomes after discharge. This study highlights areas of opportunity to improve pediatric discharge summaries. Future work should be focused on educational and systems-based interventions to improve documentation.
高质量出院小结对于确保安全的护理转接至关重要。不足之处可能导致沟通失误和不良后果。在本研究中，我们试图描述儿科出院小结的完整性、准确性和质量。
对2016年7月至2017年10月从普通儿科服务出院的患者的200份出院小结进行回顾性图表审查。这些小结针对7个要素进行审核：入院日期、出院日期、出院诊断、药物、免疫接种、待完成的实验室检查和随访预约。通过图表审查验证准确性。使用改良的经过验证的出院小结评估工具评估住院过程和患者指导的质量。收集的其他数据包括患者的医疗复杂性和作者数量。采用方差分析、χ检验和Pearson相关性分析数据。
出院诊断、药物和随访预约的完成率和准确率最低。住院过程和患者指导的质量参差不齐，基于作者数量或医疗复杂性的质量评分未见统计学意义。与无慢性病的患者相比，有基线慢性病的患者出院用药的不准确之处更多（63%对35%；P<0.001）。
出院小结文件的内容和质量不一致，对出院后的患者结局有影响。本研究突出了改进儿科出院小结的机会领域。未来的工作应侧重于基于教育和系统的干预措施，以改善文件记录。
