文章基本信息

标题：Quality of discharge summaries prepared by first year internal medicine residents
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作者：Kimberly Legault ; Jacqueline Ostro ; Zahira Khalid 等
期刊名称：BMC Medical Education
印刷版ISSN：1472-6920
出版年度：2012
卷号：12
期号：1
页码：1-6
DOI：10.1186/1472-6920-12-77
出版社：BioMed Central
摘要：Patients are particularly susceptible to medical error during transitions from inpatient to outpatient care. We evaluated discharge summaries produced by incoming postgraduate year 1 (PGY-1) internal medicine residents for their completeness, accuracy, and relevance to family physicians. Consecutive discharge summaries prepared by PGY-1 residents for patients discharged from internal medicine wards were retrospectively evaluated by two independent reviewers for presence and accuracy of essential domains described by the Joint Commission for Hospital Accreditation. Family physicians rated the relevance of a separate sample of discharge summaries on domains that family physicians deemed important in previous studies. Ninety discharge summaries were assessed for completeness and accuracy. Most items were completely reported with a given item missing in 5% of summaries or fewer, with the exception of the reason for medication changes, which was missing in 15.9% of summaries. Discharge medication lists, medication changes, and the reason for medication changes—when present—were inaccurate in 35.7%, 29.5%, and 37.7% of summaries, respectively. Twenty-one family physicians reviewed 68 discharge summaries. Communication of follow-up plans for further investigations was the most frequently identified area for improvement with 27.7% of summaries rated as insufficient. This study found that medication details were frequently omitted or inaccurate, and that family physicians identified lack of clarity about follow-up plans regarding further investigations and visits to other consultants as the areas requiring the most improvement. Our findings will aid in the development of educational interventions for residents.
关键词：Family Physician;Medication Change;Discharge Summary;Internal Medicine Resident;Medication Reconciliation