A Quality Improvement Approach to Improving Discharge Documentation

Abstract

Supplemental Digital Content is available in the text. Introduction: Accurate discharge documentation is critical to ensuring a safe and effective transition of care following hospitalization, yet many discharge summaries do not meet consensus standards for content. A local needs assessment demonstrated gaps in documentation of 3 essential elements: discharge diagnosis, discharge medications, and follow-up appointments. This study aimed to increase the completion of three discharge elements from a baseline of 45% by 20 percentage points over 16 months for patients discharged from the general pediatrics service. Methods: Ten discharge summaries were randomly selected and analyzed during each successive 2-week time period. Plan-Do-Study-Act cycles aimed to improve provider knowledge of essential discharge summary content, clarify communication during rounds, and create electronic health record shortcuts and quick-reference tools. Results: The percentage of discharge summaries containing all 3 required elements increased from 45% to 73%. Specifically, documentation increased for discharge diagnosis (65%–87%), discharge medications (71%–90%), and follow-up appointments (88%–93%). There was no significant delay in discharge summary completion. Conclusions: Discharge summaries are meaningfully and sustainably improved through provider education, workflows for clear communication, and electronic health record optimization.