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. This had the potential to compromise the continuity of care to other healthcare providers upon discharge. The introduction of an electronic discharge summary template (EDST) aimed to address this issue by providing guidance to clinicians for comprehensive documentation and handover.

METHODS: The EDST was developed through a structured process involving feedback from healthcare professionals obtained via structured interviews and questionnaires. One hundred discharge letters were chosen through sample randomization and audited against the EDST criteria. Subsequently, formal training sessions were conducted for foundation year doctors on the utilisation of the template. Post-implementation, another one hundred discharge letters were analysed to evaluate the impact of the EDST.

RESULTS: Initial analysis revealed areas requiring improvement, particularly the Barthel score on admission and discharge, patient weight, and cognitive assessment. Following implementation of the EDST, significant improvements were observed in these areas. Feedback from foundation doctors utilising the EDST guided further refinements to the template.

CONCLUSION: The introduction of the EDST resulted in improved documentation and overall discharge summary completeness. The sustained utilisation of the EDST within our hospital’s electronic discharge system is recommended to support ongoing improvements in discharge communication and patient care continuity.