Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care

Excerpt

Objectives: The Joint Commission mandates that six components be present in all U.S. hospital discharge summaries. Despite the critical importance of discharge summaries in care transitions and patient safety, no studies have examined how well discharge summaries adhere to Joint Commission standards. Methods: Joint Commission-mandated discharge summary components were specifically defined and abstracted from discharge summaries for all hip fracture, stroke, and cancer patients discharged directly to subacute care facilities from a large Midwestern academic hospital between 2003 and 2005 (N = 599). Results: Preliminary results show that most (88–100 percent) discharge summaries included five of the six Joint Commission components. The remaining component, “patient’s discharge condition,” was included the least often (79–90 percent). Conclusions: Overall, discharge summaries adhere well to Joint Commission discharge summary component standards. However, given the discharge summary’s pivotal communication role in care transitions, even a small frequency of omitted patient discharge condition information is a concern and may affect patient safety.