Assessment of Surgical Discharge Summaries and Evaluation of a New Quality Improvement Model

作者：Stein Ran; Neufeld David; Shwartz Ivan; Erez Ilan; Haas Ilana; Magen Ada; Glas**erg Elon; Shmulevsky Pavel; Paran Haim^*

来源：Israel Medical Association Journal, 2014, 16(11): 714-717.

• elective surgery
• hospital discharge summary
• quality assessment
• quality improvement
• training and education

Background: Distharge Surnmaries after hospitalization provide the most reliable description and implications of the hospitalization. A concise discharge summary is crucial for Maintaining continuity of care through the transition from inpatient to ambulatory care. Discharge summaries often lack information and are irnpreciSe. Errors and insufficient recommendations regarding changes in the medical regimen may harm the patients health and may reSult in readmiSsion.
Objectives: TO evaluate a quality improvement Model and training program for writing postoperative discharge summaries for three SUrgical procedures.
Methods: Medical records and surgical discharge summaries were reviewed and stored. Etsential pints for communication between surgeons and family physicians were included in automated forms. Staff-was briefed twice regarding required Summary contents With an interim evaluation. Changes in quality were evaluated.
Results: Summaries from 61 Cholecystectomies, 42 hernioplasties and 45 colectomies were reviewed. The average quality score of all discharge summaries increased from 12.1 to 78.3 after the first intervention (P< 0.0005) to 81.0 following the second intervention: As the discharge summary's quality improved, its length decreased significantly.
Conclusions: Discharge suMmaries lack important information and are too long. Developing a model for discharge summaries and instructing surgical staff regarding their contents resulted in measurable improvement. Frequent interventions and supervision are needed-to maintain the quality of the surgical discharge Summary.

• 出版日期2014-11