Confusing Discharge Summaries Are Hurting Patient Care

Most physicians are dissatisfied with hospital discharge summaries because of medical jargon, documentation errors, and inconsistencies. A survey conducted by Leonard Fehring and colleagues from the Faculty of Health, School of Medicine, Witten/Herdecke University in Witten, Germany, found that only 36.9% of physicians were satisfied with the current format and content.

The study, published in the Journal of General Internal Medicine, surveyed 602 physicians, 317 private general practitioners (GPs), and 285 hospital physicians, to improve diagnostic documentation. The analysis revealed that 95.7% of physicians considered the diagnosis section crucial for follow-up care. The majority (91.2%) supported standardising the diagnosis section.

According to the survey, inconsistent structure, specialty-specific abbreviations, and missing International Classification of Diseases, 10th Revision (ICD-10) codes were key concerns, contributing to miscommunication and increased administrative workload.

Satisfaction rates were low for GPs. The main concerns were a lack of interoperability with practice and hospital software (10.9% satisfaction), incomplete information (27.9% satisfaction), and a lack of clear structure, such as headings or organised sections (28.1% satisfaction).

Common Challenges

The most critical factors cited by physicians were “copy-pasting from prior discharge summaries without review” (96.1%), “time pressure” (89.4%), “deficient admission documentation” (82.6%), and “lack of general guidelines/conventions” (70.4%).

The study identified 18 key elements to be included in every current treatment diagnosis. A strong consensus (> 95.0% agreement) was reached for rated as particularly important by 95% of respondents.

• Name of the diagnosis including ICD-10 code
• Severity, stage, grading, or Tumour, Node, Metastasis classification
• Localisation (eg, bilateral, right), extent (eg, 5 cm, large area), and pattern of involvement
• Course (eg, acute, chronic, recurrent)
• Severity (eg, symptomatic, asymptomatic)
• Complications
• Date of initial diagnosis
• Aetiology/cause (eg, nosocomial, community-acquired)

Additionally, 86.4% of respondents preferred separating current and chronic/prior diagnoses with headings.

The study results also highlight differences between hospital physicians and GPs. Among GPs, 95.6% considered ICD-10 codes essential for integrating diagnoses into their IT systems, whereas only 61.1% of hospital physicians found this necessary (P < .001).

Additionally, private practice physicians were significantly more likely than hospital-based colleagues to consider concrete recommendations for further measures (76.6% vs 63.6%; P < .001) and information on follow-up appointments (77.3% vs 63.5%; P < .001) as necessary.

Future Implementation

Fehring and colleagues reported an overwhelmingly positive response to the effort to standardise the diagnostic header, calling it a “very important topic.”

The authors hope that their findings will be incorporated into the design of the electronic hospital discharge letter, which is currently being developed by the German National Association of Statutory Health Insurance Physicians.

They also emphasised the importance of integrating these findings into hospital information systems to ensure that inpatient physicians have the technical prerequisites needed to complete the diagnostic header quickly and efficiently.

This story was translated from Medscape’s German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.