CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne
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Randomized Controlled Trial Clinical Trial
Dictated versus database-generated discharge summaries: a randomized clinical trial.
Hospital discharge summaries communicate information necessary for continuing patient care. They are most commonly generated by voice dictation and are often of poor quality. The objective of this study was to compare discharge summaries created by voice dictation with those generated from a clinical database. ⋯ The database system significantly increased the likelihood that a discharge summary was created. Housestaff preferred the database system for summary generation. Physicians thought that the quality of summaries generated by the 2 methods was similar. The use of computer databases to create hospital discharge summaries is promising and merits further study and refinement.