Evaluating an implementation of the Australian National Guidelines for the On-Screen Display of Discharge Summaries
Masarrat Mahera A , Hamish Rodda B C , Nick Monypenny B and Paul Wembridge
D E *
A Monash University Eastern Health Clinical School, Box Hill, Vic. 3128, Australia.
B eHealth Department, Eastern Health, 8 Arnold Street, Box Hill, Vic. 3128, Australia.
C Emergency Department, Eastern Health, 8 Arnold Street, Box Hill, Vic. 3128, Australia.
D Department of Quality, Planning and Innovation, Eastern Health, 8 Arnold Street, Box Hill, Vic. 3128, Australia.
E Pharmacy Department, Eastern Health, 8 Arnold Street, Box Hill, Vic. 3128, Australia.
Australian Health Review 47(5) 535-544 https://doi.org/10.1071/AH22248
Submitted: 2 November 2022 Accepted: 14 July 2023 Published: 4 August 2023
Abstract
The objective of this study was to evaluate changes in the inclusion of pertinent information on electronic discharge summaries (eDS) after implementation of a revised template and electronic medical record (EMR) workflow.
A retrospective medical record audit of eDS at three metropolitan hospitals was undertaken for adult inpatient encounters in June 2021 (pre-intervention, n = 100) and June 2022 (post-intervention, n = 100). The eDS were evaluated against 16 components listed in the Australian National Guidelines for the On-Screen Display of Discharge Summaries. Nine components were further broken down to between two and 11 sub-components. Sub-analysis compared a hospital with full EMR to pooled results from hospitals with hybrid EMRs. Components and sub-components were evaluated for inclusion only; accuracy or relevance of the information was not assessed.
Inclusion of three out of 16 components (presentation details: 47% vs 62%, problems and diagnosis: 61% vs 86% and recipient details: 82% vs 93%) and eight out of 36 sub-components (discharge destination, principal diagnosis, history of presenting complaint, infection risk, pressure injury, screening and/or diagnosis of delirium and GP phone number and address) was higher in the post-intervention group (all P < 0.05). Reduced eDS information inclusion in the post-intervention group was observed for discharge date and falls risk only (both P < 0.05). Reporting of falls history decreased at the hospital with full EMR (71% vs 20% P < 0.001) but not at hospitals utilising hybrid EMRs (24% vs 30% P = 0.5).
The intervention was associated with improved inclusion of pertinent information as described in the Australian National Guidelines for the On-Screen Display of Discharge Summaries.
Keywords: accreditation, communication, discharge, discharge summary, electronic medical record, health services management, health services research, hospital, information management, quality and safety.
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