Templating for Success: Standardization of Internal Medicine Discharge Summaries at Walter Reed National Military Medical Center

From the 2021 HVPAA National Conference

Samara Lieberman (Walter Reed National Military Medical Center), John Blickle, Zachary Haynes, Adam Barelski, Alison Colantino

Background

Walter Reed National Military Medical Center (WRNMMC) utilizes an Electronic Medical Record specific to the Defense Health Agency (Essentris/CliniComp) for which discharge summaries require a free-text summary of the hospital course. Prior to the intervention in this study, in order to[CAMCW1] improve discharge efficiency, Internal Medicine residents created and distributed non-standardized, non-validated template documents to the members of their ward teams. This created confusion among medical students, residents, outpatient providers, and patients regarding the intended audience and objectives of discharge documentation[CAMCW2] and resulted in wide variability in the content and structure of free text narratives.[BAMCW3] There was also inconsistency in the key events and data that were shared through a discharge summary, raising concerns that important care plan information was lost at care transition points. Both medication discrepancies and inaccurate documentation of pending testing results in discharge documentation have been shown to directly lead to patient harm [1, 2]. Recognizing the importance of discharge summaries in safe transitions of care, leading medical professional societies met in 2009 and published a consensus policy statement, the Transitions of Care Consensus Conference (TOCCC), delineating the elements of appropriate discharge documentation [3].

Objective 

Over one year, measurably improve the quality of transitions from inpatient to outpatient care at WRNMMC through the development of a standardized Discharge Summary template reflecting current evidence-based practices with an associated didactic curriculum on the elements of effective discharge documentation.

Methods

We developed a standardized discharge summary template utilizing TOCCC recommendations. The template was then reviewed and revised by the WRNMMC Internal Medicine Hospitalist service, core Internal Medicine Clinic faculty, and Internal Medicine Residency leadership. In addition, we created and delivered a didactic curriculum and written materials for medical students and residents delineating the components of quality discharge summaries and accurate and efficient template completion. We evaluated the quality of discharge summaries with a TOCCC-based grading rubric[CAMCW4] applied to 14 randomly selected discharge summaries prior to intervention (Oct-Dec 2019) and 1 year after intervention (Oct-Dec 2020).

Results

On review of 14 discharge summaries before and after implementation of a standardized discharge summary template, the average rubric score was 48.1% (± 7.8%) versus 73.3% (± 13.3%), a difference of 25.2% (CI 16.71%, 33.69%, p<0.0001). Key elements identified by the TOCCC including cognitive status at discharge and code status were not present in any pre-intervention discharge summaries and present in all post-intervention discharge summaries.

Conclusions

Standardized, comprehensive discharge documentation is essential to safe transitions of care from the inpatient to the outpatient setting. Prior to the implementation of a standardized template, multiple key elements were routinely absent or ineffectively communicated by WRNMMC discharge summaries. Development and distribution of a standardized template with an accompanying didactic curriculum and guidance materials led to a quality improvement of 25% over a one-year period within the Internal Medicine residency.

Clinical Implications

The importance of comprehensive and effective discharge documentation after an inpatient admission for patient safety and ongoing quality care is well-defined. The wide distribution of a standardized template with resultant significant improvement in documentation quality leads to improved safety of transitions of care for patients admitted to the WRNMMC Internal Medicine service.

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