A Structured Workshop to Improve the Quality of Resident Discharge Summaries

• DOI: 10.4300/jgme-d-10-00249.1
• Publication Date: 2013-07-10T19:56:22Z
• Authors: Jaideep S. Talwalkar; Jason R. Ouellette; Shawnette Alston; Gregory K. Buller; Daniel Cottrell; Thomas Genese; Ali Vaezy
• Keywords: 03 medical and health sciences; 0302 clinical medicine; 3. Good health

Abstract Background Poor communication at hospital discharge can increase the risk of adverse events. The summary is most common tool for detailing events related to hospitalization in preparation postdischarge follow-up, yet deficiencies summaries have been widely reported. Resident physicians are expected dictate but receive little formal training this arena. We hypothesized that implementation an educational program on chart documentation skills would result improvements quality a community internal medicine residency program. Methods A monthly, 1-hour workshop was launched August 2007 provide consistent and ongoing instruction documentation. Guided by faculty moderator, residents reviewed 2 randomly selected peer notes per session using instruments developed purpose. After had place years, 4 members 63 from spring 2007, 2008, 2009 14-item evaluation tool. Results Mean scores 10 14 individual items improved stepwise manner during 3 years study. Items overall showed statistically significant improvement, as did portion “carbon copied” responsible outpatient physician. Conclusions following novel, structured teach skills. Ongoing improvement seen 1 into program, suggesting continuing those beneficial.