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Appl Clin Inform 2018; 09(03): 734-742
DOI: 10.1055/s-0038-1669461
Research Article

Integrated Electronic Discharge Summaries—Experience of a Tertiary Pediatric Institution

Authors

  • Daryl R. Cheng

    1   EMR Project Team, The Royal Children's Hospital Melbourne, Parkville, Australia
    2   Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Australia

  • Merav L. Katz

    1   EMR Project Team, The Royal Children's Hospital Melbourne, Parkville, Australia

  • Mike South

    1   EMR Project Team, The Royal Children's Hospital Melbourne, Parkville, Australia
    2   Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Australia
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Abstract

Objective Succinct and timely discharge summaries (DSs) facilitate ongoing care for patients discharged from acute care settings. Many institutions have introduced electronic DS (eDS) templates to improve quality and timeliness of clinical correspondence. However, significant intrahospital and intraunit variability and application exists. A review of the literature and guidelines revealed 13 key elements that should be included in a best practice DS. This was compared against our pediatric institution's eDS template—housed within an integrated electronic medical record (EMR) and used across most inpatient hospital units.

Methods Uptake and adherence to the suggested key elements was measured by comparing all DSs for long stay inpatients (> 21-day admission) during the first year of the EMR eDS template's usage (May 2016–April 2017).

Results A total of 472 DSs were evaluated. Six of 13 key elements were completed in > 98.0% of DSs. Conversely, only < 5.0% included allergies or adverse reaction data, and < 11.0% included ceased medications or pending laboratory results. Inclusion of procedure information and pending laboratory results significantly improved with time (p = 0.05 and p < 0.04, respectively), likely as doctors became more familiar with EMR and autopopulation functions. Inclusion of “discharge diagnosis” differed significantly between medical (n = 406/472; 99.0%) and surgical (n = 32/472; 51.6%) DSs.

Conclusion Uptake and adherence to an EMR eDS template designed to meet best practice guidelines in a pediatric institution was strong, although significant improvements in specific data elements are needed. Strategies can include a modification of existing eDS templates and junior medical staff education around best practice.

Keywords

best practice - discharge summaries - electronic medical records - template

Protection of Human and Animal Subjects

This study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by RCH Human Research Ethics Committee (HREC #DA001-2017-102).




Publication History

Received: 18 April 2018

Accepted: 29 July 2018

Publication Date:
19 September 2018 (online)

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