Background: The quality of discharge documentation in patients discharged to rehabilitation centers and other subacute facilities is less well studied than that of patients discharged home.
Objective: To evaluate the quality of information transfer among patients discharged from acute hospitals to subacute facilities across an integrated healthcare delivery system.
Design: Retrospective evaluation of discharge documentation packets of selected patients.
Setting: Five acute care hospitals of the Partners Healthcare System.
Measurements: We measured the presence of specific data elements required to safely care for patients after discharge, including all data elements required by the Joint Commission on Accreditation of Healthcare Organizations (TJC).
Results: A total of 1501 discharge documentation packets were reviewed from March 2005 through June 2007. Only 1055 (70.3%) discharge summaries had all the information required by TJC, with physical examination at admission and condition at discharge most often missing (in 11.4% and 14.2% of cases, respectively). Other deficiencies not mandated by TJC included a list of preadmission medications (missing in 20.3%) and reasons for changes in these medications at discharge (35.3%), mention of pending test results (47.2%), and postdischarge management and follow-up plans (11.1%).
Conclusions: We found room for improvement in the inclusion of data elements required for the safe transfer of patients from acute hospitals to subacute facilities, especially in areas such as medication reconciliation, pending test results, and adequate follow-up plans.
Copyright 2009 Society of Hospital Medicine