Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria

Rationale and objective: The discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations. Method: One hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4-point Likert-type scale ranging from strongly agree to strongly disagree (or not relevant). Subsequently, the results were discussed among reviewers to achieve a consensus decision. Results: The mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS. Conclusions: In conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations.

Automated summary

The study analyzed important components, structural characteristics, and medical and general abbreviations in discharge summaries. Key findings include that 80% of DS included reason for admission and diagnosis at discharge, 48% fully scored last medication, and 94% had recommended medication clearly listed. Significant differences among clinics were found for nine mandatory items.