The application of a computer data base system to the generation of hospital discharge summaries

Abstract

The task of maintaining accurate and timely records of resident experiences, as well as section and departmental statistical data, may be readily accomplished with many commercially available computer data base packages. The application of this type of technology to the generation of "narrative" discharge summaries represents an extension of these applications and an incentive for house officer compliance. A system of data gathering and reporting, combined with the generation of discharge summaries, letters to referring physicians, and billing work sheets, has been in use in the Department of Obstetrics and Gynecology at The Medical College of Georgia for 2 years. A group of 103 patients discharged during the month of October 1985 served as controls for a comparable prospective group of 104 patients discharged beginning October 1, 1987. Analysis shows an average (+/- SEM) of 3.8 +/- 0.6 days from discharge to printed discharge summary from the computer system. Before implementation of the system (1985), the average was 20.9 +/- 4.5 days. This difference was statistically significant at P = .001. Although it may be difficult to quantitate improvement in quality of the data obtained for residency and departmental purposes, this reduction in delinquent charts alone may be sufficient to recommend the application of computer technology to this problem.