Monday, September 28, 2009

Discharge Summaries Grossly Inadequate at Documenting Pending Test Results

A study in the September edition of the Journal of General Internal Medicine found that "discharge summaries are grossly inadequate at documenting both tests with pending results and the appropriate follow-up providers."

The study found that only 13% of discharge summaries document all pending tests. And only 25% of discharge summaries mention some pending tests. Follow-up providers information was included in 67% of discharge summaries. "The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return." The study evaluated discharge summaries at two academic medical centers for patients that had pending test results.

This adds to the communication challenges referring physicians face coordinating care in follow-up to a hospital visit. Yet communications issues are accountable for over half of all preventable errors. And communications issues are twice as likely to be related to deaths as compared to "clinical inadequacy".

The study reported that approximately 41% of patient are discharged with pending test results and 9% of these test results affect patient care management.


Anonymous said...

I am not surprised about the lack of documentation in discharge summaries. When I was still able to work, I worked for a company who had a contract with the federal government to review quality of care issues for Medicare and Medicaid patients. By far, the top quality concern found after reviewing the patient record was in a category we called 2d which was failure to document follow up of abnormal labs and other tests.

eppie w. said...

I know this was true so it probably still is true. I use to work for a peer review organization that contracted with the federal government to review Medicare and Medicaid patient records. Lack of documentation of follow up of tests was the most cited problem regarding quality concerns.