Creating High-Quality Discharge Summaries

Medical Informatics

Creating High-Quality Discharge Summaries that are Integrated with the Electronic Patient Record

Discharge summaries are often illegible, not informative or received too late for the information to be considered clinically useful. Electronic discharge summaries can address known deficiencies and improve the continuity of care, communication and accuracy of data in discharge summaries. The University Health Network has developed a web-based discharge summary that is integrated with the hospital’s electronic patient record (EPR) and has the capacity to be tailored to meet the needs of different clinical specialties. The application automatically populates notes with patient demographic and allergy information, as well as pertinent laboratory and radiology results. It is also pre-populated with medications and is integrated with the pharmacy medication reconciliation system. In addition, the application allows physicians to generate an electronic prescription directly from the medications listed in the discharge summary. With the implementation of a web-based electronic discharge summary we were able to address known issues in prescribing practices, decrease the time from patient discharge to note completion and eliminate costs associated with transcription. By pre-populating the note with data from the electronic patient record we have helped to improve the quality and accuracy of data contained within the discharge summary. The success of the project is attributed to involving physicians with the design and functionality of the discharge summary application and the ability to leverage information that is currently stored in the electronic patient record. It is anticipated that this strategy can be easily adapted to other healthcare institutions.