• Amy J H Kind, Carolyn T Thorpe, Justin A Sattin, Stacy E Walz, and Maureen A Smith.
• Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. ajk@medicine.wisc.edu
• J Gen Intern Med. 2012 Jan 1; 27 (1): 78-84.

BackgroundDischarge summaries play a pivotal role in the transitional care of patients discharged to sub-acute care facilities, but the best ways to facilitate document completeness/quality remain unknown.ObjectiveTo examine the relationship among clinical-work processes, provider characteristics, and discharge summary content to identify approaches that promote high-quality discharge documentation.DesignRetrospective cohort study.SubjectsAll hip fracture and stroke patients discharged to sub-acute care facilities during 2003-2005 from a large Midwestern academic medical center (N = 489). Patients on hospice/comfort care were excluded.Main MeasuresWe abstracted 32 expert-recommended components in four categories ('patient's medical course,' 'functional/cognitive ability at discharge,' 'future plan of care,' and 'name/contact information') from the discharge summaries of sample patients. We examined predictors for the number of included components within each category using Poisson regression models. Predictors included work processes (document completion in relation to discharge day; completion time of day) and provider characteristics (training year; specialty).Key ResultsHistorical components (i.e., 'patient's medical course' category) were included more often than components that directly inform the admission orders in the sub-acute care facility (i.e., 'future plan of care'). In this latter category, most summaries included a discharge medication list (99%), disposition (90%), and instructions for follow-up (91%), but less frequently included diet (68%), activity instructions (58%), therapy orders (56%), prognosis/diagnosis communication to patient/family (15%), code status (7%), and pending studies (6%). 'Future plan of care' components were more likely to be omitted if a discharge summary was created >24 h after discharge (incident rate ratio = 0.91, 95% confidence interval = 0.84-0.98) or if an intern created the summary (0.90, 0.83-0.97).ConclusionCritical component omissions in discharge summaries were common, and were associated with delayed document creation and less experienced providers. More research is needed to understand the impact of discharge documentation quality on patient/system outcomes.

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