Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers

• Published in: Journal of general internal medicine : JGIM Vol. 24; no. 9; pp. 1002 - 1006
• Main Authors: Were, Martin C., Li, Xiaochun, Kesterson, Joe, Cadwallader, Jason, Asirwa, Chite, Khan, Babar, Rosenman, Marc B.
• Format: Journal Article
• Language: English
• Published: New York Springer-Verlag 01-09-2009; Springer; Springer Nature B.V
• Subjects: Adult; Aged; Aged, 80 and over; Ambulatory Care - methods; Ambulatory Care - standards; Biological and medical sciences; Continuity of Patient Care - standards; Diagnostic Tests, Routine - standards; Discharge; Documentation - methods; Documentation - standards; Electronic health records; Female; Follow-Up Studies; General aspects; Health participants; Health Personnel - standards; Hospital Medicine; Humans; Internal Medicine; Male; Medical errors; Medical Errors - prevention & control; Medical Records - standards; Medical sciences; Medical tests; Medicine; Medicine & Public Health; Middle Aged; Miscellaneous; Patient Discharge - standards; Patient safety; Public health. Hygiene; Public health. Hygiene-occupational medicine; Retrospective Studies; Young Adult; medical errors; patient safety; tests with pending results; continuity of care; discharge summary; Continuity of care; Human; Hospital discharge; Iatrogenic; Malpractice; Medical error; Patient; Discharge; Result; Medicine; Follow up study; Complication; Ambulatory; Safety; Public health
• ISSN: 0884-8734; 1525-1497
• DOI: 10.1007/s11606-009-1057-y

ABSTRACT
BACKGROUND
Poor communication of tests whose results are pending at hospital discharge can lead to medical errors.
OBJECTIVE
To determine the adequacy with which hospital discharge summaries document tests with pending results and the appropriate follow-up providers.
DESIGN
Retrospective study of a randomly selected sample
PATIENTS
Six hundred ninety-six patients discharged from two large academic medical centers, who had test results identified as pending at discharge through queries of electronic medical records.
INTERVENTION AND MEASUREMENTS
Each patient’s discharge summary was reviewed to identify whether information about pending tests and follow-up providers was mentioned. Factors associated with documentation were explored using clustered multivariable regression models.
MAIN RESULTS
Discharge summaries were available for 99.2% of 668 patients whose data were analyzed. These summaries mentioned only 16% of tests with pending results (482 of 2,927). Even though all study patients had tests with pending results, only 25% of discharge summaries mentioned any pending tests, with 13% documenting all pending tests. The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return. Follow-up providers’ information was documented in 67% of summaries.
CONCLUSION
Discharge summaries are grossly inadequate at documenting both tests with pending results and the appropriate follow-up providers.