Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries

被引:17
|
作者
Lehnbom, Elin C. [1 ]
Raban, Magdalena Z. [2 ]
Walter, Scott R. [2 ]
Richardson, Katrina [3 ]
Westbrook, Johanna I. [2 ]
机构
[1] Univ New S Wales, UNSW Med, Australian Inst Hlth Innovat, Ctr Hlth Syst & Safety Res, Unsw Sydney, NSW 2052, Australia
[2] Univ New S Wales, Australian Inst Hlth Innovat, Ctr Hlth Syst & Safety Res, Sydney, NSW 2052, Australia
[3] St Vincents Hlth Australia NSW, IT Serv Ctr, Rushcutters Bay, NSW 2011, Australia
关键词
Patient Discharge Summaries; Electronic Health Records; Medication Reconciliation; Medication Therapy Management; Patient Care Management; Continuity of Patient Care; PATIENTS AFTER-DISCHARGE; ADVERSE EVENTS; PRIMARY-CARE; RECONCILIATION; QUALITY; ERRORS; DISCREPANCIES; COMMUNICATION; ADMISSION; READMISSIONS;
D O I
10.1177/183335831404300301
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
Complete, accurate and timely hospital discharge summaries are important for continuity of care. The aim of this study was to evaluate the effectiveness of an electronic discharge summary system in improving the medication information provided compared to the information in paper discharge summaries. We conducted a retrospective audit of 199 paper and 200 electronic discharge summaries from a 350-bed teaching hospital in Sydney, Australia. The completeness of medication information, and whether medication changes during the admission were explained, were assessed. Further, the likelihood of any incomplete information having an impact on continuity of care was assessed. There were 1352 and 1771 medication orders assessed in paper and electronic discharge summaries, respectively. Of these, 90.9% and 93.4% were complete in paper and electronic discharge summaries, respectively. The dose (OR 25.24, 95% CI: 3.41-186.9) and route (OR 8.65, 95% CI: 3.46-21.59) fields of medication orders, were more likely to be complete in electronic as compared with paper discharge summaries. There was no difference for drug frequency (OR 1.09, 95% CI: 0.77-1.55). There was no significant improvement in the proportion of incomplete medication orders rated as unclear and likely to impede continuity of care in paper compared with electronic discharge summaries (7.3% vs. 6.5%). Of changes to medication regimen, only medication additions were more likely to be explained in the electronic (n=253, 37.2%) compared to paper (n=104, 14.3%) discharge summaries (OR 3.14; 95% CI: 2.20-4.18). In summary, electronic discharge summaries offer some improvements over paper discharge summaries in terms of the quality of medication information documented. However, explanations of changes to medication regimens remained low, despite this being crucial information. Future efforts should focus on including the rationale for changes to medication regimens in discharge summaries.
引用
收藏
页码:4 / 12
页数:9
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