Discharge Summary: Reflections and Proposal for a Practical Guide
DOI:
https://doi.org/10.24950/rspmi.2704Keywords:
Electronic Health Records, Medical Records, Problem-Oriented, Patient Discharge, Patient Discharge Summaries, Transitional CareAbstract
A discharge summary is a clinical report relative to an episode of hospitalization. Its role is to ensure the transition of care between healthcare teams. Writing a discharge summary is a structured exercise of synthesizing relevant information, explaining the reasoning behind decisions and communicating the healthcare plan. A discharge summary is an opportunity to look at the patient´s situation as a whole and to update the priorities of their individual care plan. The Government determined a set of minimum mandatory information to normalize discharge summaries. This instrument is useful, but it does not replace the clinical report itself, which is a highly personalized document, impossible to parameterize. To ensure that a free field text is not structurally fragile, it is necessary to adopt a recording system that allows dealing with complex systems, such as problem-oriented medical records. In practical terms, a guide for writing problem-oriented discharge notes is proposed.
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1. Oliveira PJ. A importância da qualidade dos registos médicos para os hospitais [Dissertação de mestrado, ISCTE - Instituto Universitário de Lisboa]. Lisboa: ISCTE; 2015. Disponível em: http://hdl.handle.net/10071/11651
2. Carneiro R, Simões C, Carneiro AH. Plano Individual e Integrado de Cuidados Como Objetivo da Relação Clínica. Med Interna.2019;18:147-52. doi: 10.24950/rspmi/PV/284/18/2/2019.
3. Guilcher SJ, Fernandes O, Luke MJ, Wong G, Lui P, Cameron K, et al. A developmental evaluation of an intraprofessional Pharmacy Communication Partnership (PROMPT) to improve transitions in care from hospital to
community: A mixed-methods study. BMC Health Serv Res. 2020;20:99. doi: 10.1186/s12913-020-4909-0.
4. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51:549-55. doi: 10.1046/j.1532-5415.2003.51185.x.
5. Bean WB. Sir William Osler: Aphorisms from His Bedside Teachings and Writings. New York: Henry Schuman, Inc; 1950. 6. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278:593-600. doi: 10.1056/NEJM196803142781105.
7. Barreto JV, Paiva P. 2008. O registo clínico orientado por problemas. Med Interna. 2008;15:201–6.8. Varela A, Rola J. Nota de alta hospitalar--que informação clínica para o médico de família. Acta Méd Port.2000;13:81–4. doi: 10.20344/
amp.1777.
9. Kind AJ, Smith MA. Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville: Agency for Healthcare Research and Quality (US); 2008.
10. Correia C, Rodrigues L, Lopes L, Nunes L, Neves C, Almeida J,et al. Avaliação do desempenho médico através da qualidade do registo dos processos clínicos. Med Interna. 1995;2:7–12.
11. Barata C, Azevedo F. Qualidade do processo clínico – estudo comparativo 2004-2005. Med Interna. 2011;18:4–10.
12. Reid DB, Parsons SR, Gill SD, Hughes AJ. Discharge communication from inpatient care: an audit of written medical discharge summary procedure against the new National Health Service Standard for clinical handover. Aust Health Rev. 2015;39:197-201. doi: 10.1071/AH14095.
13. Tulloch AJ, Fowler GH, McMullan JJ, Spence JM. Hospital discharge reports: content and design. Br Med J. 1975;4:443-6. doi: 10.1136/bmj.4.5994.443.
14. Bado W, Williams CJ. Usefulness of letters from hospitals to general practitioners. Br Med J. 1984;288:1813-4. doi: 10.1136/bmj.288.6433.1813.
15. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-41. doi: 10.1001/jama.297.8.831.
16. Kamalodeen S. How to Write a Discharge Summary. [accessed feb 2018] Avaialble at: geekymedics.com/how-to-write-a-discharge-summary.
17. Waddell AE, Yue Y, Comrie R, Wong BM, Kurdyak PA. Effects of the Implementation of a Patient-Oriented Discharge Summary (PODS) on Pre- and Postdischarge Outcomes. Psychiatr Serv. 2023;74:1204-7. doi: 10.1176/appi.ps.20220309.
18. Kergoat MJ, Latour J, Julien I, Plante MA, Lebel P, Mainville D,et al. A discharge summary adapted to the frail elderly to ensure transfer of relevant information from the hospital to community settings: a model. BMC Geriatr. 2010;10:69. doi: 10.1186/1471-2318-10-69.
19. Solomon JK, Maxwell RB, Hopkins AP. Content of a discharge summary from a medical ward: views of general practitioners and hospital doctors. J R Coll Physicians Lond. 1995;29:307-10.
20. Ministério da Saúde - Gabinete do Secretário de Estado da Saúde. Despacho n.º 2784/2013, de 20 de fevereiro, Diário da República n.º 36/2013, Série II de 2013-02-20, páginas 6908 – 6909
21. Stopford E, Spencer N. How to Write a Discharge Summary. BMJ. 2015; 351. doi: 10.1136/sbmj.h2696.
22. van Walraven C, Rokosh E. What is necessary for high-quality discharge summaries? Am J Med Qual. 1999;14:160-9. doi: 10.1177/106286069901400403.
23. Chow KM, Szeto CC. Secular trends in the medical discharge summary in an acute medical hospital. Postgrad Med J. 2006;82:615-8. doi: 10.1136/pgmj.2006.046789.
24. Gama Marques J. Como Escrever Notas de Alta e Cartas de Referenciação? Uma Perspetiva Simples mas Efetiva. Acta Méd Port. 2018;31:189–90. /doi:10.20344/amp.10304.
25. Dodd K. Transitions of care - how to write a "good" discharge summary. Boston: Boston Medical Center. Inpatient Times; 2007.
26. Adams G, Alsentzer E, Ketenci M, Zucker J, Elhadad N. What's in a Summary? Laying the Groundwork for Advances in Hospital-Course Summarization. Proc Conf. 2021;2021:4794-811. doi: 10.18653/v1/2021.naacl-main.382.
27. Serviços Partilhados do Ministério da Saúde, SPMS. Norma técnica para disponibilização de notas de alta estruturadas no Registo de Saúde Eletrónico a partir dos sistemas hospitalares de registo clínico. [consultado 02-09-2019] Disponível em: https://www.spms.min-saude.pt/wp-content/uploads/2019/09/Norma-t%C3%A9cnica-para-
disponibiliza%C3%A7%C3%A3o-de-notas-de-alta-estruturadas-no-RSE-a-partir-dos-sistemas-hospitalares-de-registo-cl%C3%ADnico.pdf
28. Lenert LA, Sakaguchi FH, Weir CR. Rethinking the discharge summary: a focus on handoff communication. Acad Med. 2014r;89:393-8. doi: 10.1097/ACM.0000000000000145.
29. Araújp Correia J, Barrteto JV. Registo e raciocínio clínico / João Araújo Correia, J. Vasco Barreto. Lisboa : Lidel; 2018 [consultado fev 20204] Disponível em: http://id.bnportugal.gov.pt/bib/bibnacional/2020661
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