Improving discharge summary documentation of older adults in a rehabilitation hospital with an electronic discharge template

Abstract

Background: During past quality improvement projects at our rehabilitation hospital, inconsistencies were observed in the inclusion of essential information in discharge notes. The introduction of an electronic discharge summary template (EDST) aimed to address this by providing guidance to clinicians for comprehensive documentation. Methods: The EDST was developed through feedback from healthcare professionals using the Delphi method. 100 discharge letters were audited against the EDST criteria before and after implementation, following formal training for foundation year doctors. Results: Initial analysis revealed areas requiring improvement, particularly the Barthel score, patient weight, and cognitive assessment. Following implementation of the EDST, significant improvements were observed in these areas. Conclusion: The introduction of the EDST resulted in improved documentation and overall discharge summary completeness, supporting ongoing improvements in patient care continuity.