UAB Synopsis, Vol. 27, No. 28, July 21, 2008
The use of a template can improve residents’ discharge summaries, Department of Medicine (DOM) residents determined in an intervention piloted earlier this year.
The project was part of the American College of Graduate Medical Education requirement for residents to engage in quality improvement projects. Trina D. McKenzie, MD, a graduate of UAB’s internal medicine (IM) residency program and a Veterans Affairs National Quality Scholars Fellow, coordinated the project.
“Dictating a high quality discharge summary is a crucial component in improving care transitions for patients leaving the hospital,” Dr. McKenzie says. “Unfortunately, many discharge summaries do not include all of the required elements. The IM residents recognized this issue and designed an intervention to improve the quality of discharge summaries.”
The residents developed a template with specific definitions for each of the Health Information Management’s 15 discharge summary components and printed them on pocket cards and name badge cards as quick reminders. Seventeen residents formed the intervention group, and 18 others served as controls.
The investigators piloted the template on six inpatient medical services during February. They analyzed up to six discharge summaries from each resident for inclusion of the components and compared the groups’ scores. The dictation template significantly improved the intervention group’s completeness of discharge summaries compared with control group summaries. The vast majority of residents found the template helpful and recommended giving it to all IM residents.
Internal Medicine Residency Program Director Gustavo Heudebert, MD, plans to distribute the discharge summary template to all IM residents. “This intervention confirms that residents can play a vital role in improving quality,” he says. “Because residents are actively engaged in patient care, their ideas for improvement are invaluable.”
“As the new residents begin, this template will help them and other residents dictate more complete discharge summaries,” Dr. McKenzie says. “Providing quality care for patients is a primary goal for physicians. The IM residents have demonstrated how effective they can be in reaching this goal.”