Why Timely and Accurate Discharge Summaries Are of Vital Importance
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Timely and accurate discharge summaries are crucial for preventing patient readmissions within 30 days of discharge. Issues such as delays in dictation, unclear communication, and incomplete information can compromise the reliability of these summaries, emphasizing the need for effective medical transcription services. Ensuring that discharge summaries meet regulatory standards and are easily understandable is essential for maintaining continuity of care and improving patient outcomes.
Why Timely and Accurate Discharge Summaries Are of Vital Importance
- 1. Why Timely and Accurate Discharge Summaries Are of Vital Importance Timely and accurate transcription of discharge summaries is essential to prevent readmission within the critical 30-day time period. MEDICAL TRANSCRIPTION SERVICE COMPANY 8596 E. 101st Street, Suite H Tulsa, OK 74133 Phone: 1-800-670-2809
- 2. www.medicaltranscriptionservicecompany.com 1-800-670-2809 A discharge summary contains both clinical and administrative information about a patient’s hospital stay. It serves as a communication tool to future care providersand helps them maintain continuity of care. However, many hospitals do not spend quality time creating an accurate discharge summaryand this often forces discharged patients to return to the hospital at a very early stage. Many studies show the impact the timeliness of discharge summaries have on hospital readmissions. Given the significance of discharge summaries and the challenge hospitals may be facing in completing this in a timely manner, medical transcription outsourcing for discharge summary recordings becomes indispensable in many hospital settings. The reliability of outsourced medical transcription has increased considerably with more healthcare providers recognizing the true value of outsourcing. This trust earned by business transcription services is reflected in a recent report that indicates that the medical transcription industry is poised to grow at a CAGR (Compound Annual Growth Rate) of $4+% and reach US $1 billion by 2020. Importance of Discharge Summary Patients are given a set of instructions when they are released from the hospital. These instructions include the medications, rehabilitation therapy etc that a patient has to follow for quick recovery. Therefore the discharge summary should be accurate in order to avoid any confusion and prevent the patient’sreturn trip to the hospital. In fact, hospitalists should consider it as the most important documentation in the medical chart. Did you know that discharge summary is regulated? Yes, the Joint Commission stipulates that six important components be present in a discharge summary. 1. Reason for hospitalization 2. Significant findings 3. Procedures and treatments provided 4. Patient's discharge condition 5. Patient and family instructions (as appropriate) 6. Attending physician's signature
- 3. www.medicaltranscriptionservicecompany.com 1-800-670-2809 Why Discharge Summaries Become Unreliable There are some definite reasons why a discharge summary is often sloppy and unreliable. Let us examine some of these. Not dictating the discharge summary in a timely manner: Sometimes, subspecialty services may take many weeks to dictate their discharge summary. Speakers with heavy accents speaking too quickly for the transcriptionist to understand: This will lead to errors in the transcripts such as the funny one of a heavily accented doc asking for charts from the “wrecker” room; what he meant was obviously the “record” room. Not including the necessary and relevant information. Lengthy discharge summaries that people may be too impatient to read carefully. Failure to make the copies of the discharge summary available to the primary care physician and other subspecialists taking care of the patient. According to a recent post in The Hospitalist, a recent study that examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to evaluate whether a delay increased the odds of hospital readmission found that 14,248 patients (16.2%) were readmitted within 30 days of discharge. The researchers found a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than 3 days after discharge. The study authors concluded that completing a discharge summary within 3 days of discharge may reduce the risk of 30-day readmission. An educational program “Ask Me 3” developed by the National Patient Safety Foundation, lists the following as the three main things a patient should be clear about their post discharge instructions: The main problem: It is important to know what brought them to the hospital, whether they are suffering from any chronic condition or the visit to the hospital has been due to some new illness. This helps care providers to diagnose and decide what treatment should be provided.
- 4. www.medicaltranscriptionservicecompany.com 1-800-670-2809 What the patient should do: When the patients are given the discharge summary it is important for them to understand the medical notes and also clarify any doubts to prevent further illness or health risk. Why post discharge recommendations areimportant:Every patient should understand the importance of the discharge summary and follow the post discharge recommendations to ensure quick recovery. The ultimate goal of any hospital should be to ensure that every patient is happy and satisfied when they leave the hospital. They should also make sure that the patients feel free to call and clarify their doubts regarding the post discharge instructions if necessary. To ensure that patients do not return to the hospital within the 30 day period (the readmission rate which tracks how many patients are readmitted to the hospital within 30 days of discharge, and which is one of CMS’s star rating measurements), hospitalists must ensure that the discharge summary is timely, has the right information and be in a format that can be easily understood by other care providers.