Discharge Reports: Document Management and Guidelines

The creation and issuing of discharge summary reports is mandatory in the healthcare industry. It is often the only documentation a General Practitioner (GP) receives in relation to a recent admission. A discharge summary can be best described as a collection of important information detailing the events during care by a provider or organization. Its primary purpose is to provide as much information as possible about the clinical and administrative procedures administered during a patient’s hospital stay. A well-written discharge summary ensures that health care providers can maintain continuity and consistency of care.

However, several key issues have been identified with traditional paper-based discharge summaries. These include:

  • Time delays between actual patient discharge and the discharge summary being sent;
  • Discharge summaries containing inaccurate information; and
  • The omission of information deemed important for the patient’s safety and well-being.

These problems can eventually lead to adverse patient care including medication errors. However, electronic management of these discharge statements and automation of the process can help to alleviate these issues, introduce time and cost savings, and result in overall process efficiency.

The Challenge with Discharge Summary Reports

These reports can sometimes be complex and as such may be subject to error. Efforts to improve the quality of discharge reports have been widely recognized due to the potential risk to the patient. Healthcare organizations are often responsible for handling large volumes of discharge reports on a daily basis. Several vital inputs have been deemed necessary to be included in these summaries; they include, but are not limited to:

  • Accurate primary and secondary diagnoses
  • Physical examination findings and laboratory results
  • Investigations and procedures
  • Complications and drug allergies
  • Hospital follow up arrangements
  • Discharge medications
  • Dates of admission and discharge

Handling a multitude of reports with several manual inputs greatly increases the risk for human error. In addition, the manual management of large volumes of paperwork usually requires dedicated resources which can have an adverse effect on system efficiency and overall productivity.

Handling large volumes of paper-based discharge summaries often gives rise to the challenge of spatial requirements. Multiple filling cabinets often take up valuable office space and can inadvertently lead to office clutter. This in turn leads to delays in retrieving summary reports, increased overheads and deceased productivity.

Another challenge lies in the repetitive manual input of patient information. The manual input of information hundreds of times a day repeatedly opens the opportunity for human error to be introduced. Manual inputting information and routing of information for reviews and approvals can be greatly time consuming and often results in inconvenient delays.

Discharge Reports and Document Management

A series of initiatives have been implemented to address the shortfalls of discharge summaries and improve patient outcomes. The most common approaches to improve the quality of discharge summaries include the inclusion of automatically generated reports, changing the mode of report delivery and changing the format of discharge summaries.

One of the first ways which document management systems can be used to improve the quality of discharge summary is by the implementation of structured document templates. Structured document templates, or standardized types of reporting forms have been used to improve the quality of clinical communication. By utilizing a standardized structured template the effect of human error is reduced though simplifying the steps in the reporting process as well providing prompts to include certain types of information. Patient information can be easily input with just a few clicks of a mouse greatly reducing the time to produce a discharge summary.

Discharge summaries for returning patients can be easily retrieved using the electronic search capabilities of DMS. With just a few clicks of a mouse, a patient’s files can be found via document file name or even keywords with the document. This offers significant time savings as opposed to manually locating files within a physical filing cabinet.

Using eFileCabinet to Improve the Efficiency of Discharge Summaries

In addition to the features of DMS mentioned above, eFileCabinet also includes a couple other unique features that make it the ideal DMS for the improving the efficiency of discharge summaries.

eFileCabinet includes a full-blown workflow module that can be used to automate repeated work processes. A workflow is basically a sequence of industrial, administrative, or other processes through which a piece of work passes from initiation to completion. What this means is that with eFileCabinet, it can be used to map out the destination or sequence of processes for the discharge summary’s lifecycle. For example, the discharge summary can be automatically forwarded to the doctor, coroner, or administration department when certain predefined conditions are met.

Discharge summaries are confidential documents; eFileCabinet’s state-of-the-art security measures ensure that the valuable reports are only seen by relevant parties. All files hosted on eFileCabinet are secured with heavy 256-bit encryption security, and all files are stored on secure data centers and SSL-certified websites.

But this is just the tip of the iceberg! If you would like to find out more on how eFileCabinet’s powerful features can help improve the quality and efficiency of discharge statements please fill out the form provided for a free 15-minute demo.

By | 2016-12-15T11:59:26+00:00 November 16th, 2015|
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