Electronic Discharge Summary and Direct Data Entry for Outpatient Clinics

AbstractData are presented on the use of a browsing and encoding utility to improve coded data entry for an electronic patient record system. Traditional and computerized discharge summaries were compared: during three phases of coding ICD-9 diagnoses phase I, no coding; phase II, manual coding, and phase III, computerized semiautomatic coding. Our data indicate that (1) only 50% of all diagnoses in a discharge summary are encoded manually; (2) using a computerized browsing and encoding utility this percentage may increase by 64%; (3) when forced to encode manually, users may “shift” as much as 84% of relevant diagnoses from the appropriate coding section to other sections thereby “bypassing” the need to encode, this was reduced by up to 41 % with the computerized approach, and (4) computerized encoding can improve completeness of data encoding, from 46 to 100%. We conclude that the use of a computerized browsing and encoding tool can increase data quality and the percentage of documented data. Mechanisms bypassing the need to code can be avoided.

Download Full-text

Experience of Coding Ambulatory Visits to Outpatient Clinics

Health Information Management ◽

10.1177/183335839602600314 ◽

1996 ◽

Vol 26 (3) ◽

pp. 141-144 ◽

Cited By ~ 1

Author(s):

K Gibson ◽

J Ives ◽

M Wilson ◽

D Richardson

Keyword(s):

Data Collection ◽

Clinical Data ◽

Discharge Summary ◽

Tertiary Hospital ◽

Outpatient Clinics

Clinical data for all current outpatients at a large tertiary hospital has been collected for analysis. Patient diagnoses for selected “key” clinics have been coded to ICD-9-CM standards. Methods to reduce the volume of coding required for such data collection are discussed, and include short-lists of codes, default assignment of diagnoses codes according to the nature of visit, and producing a “discharge” summary for outpatients, similar to that routinely produced for inpatients.

Download Full-text

Using an electronic discharge notification system reduces the time delay between discharge and a summary being sent to the GP

BJPsych Open ◽

10.1192/bjo.2021.467 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S169-S169

Author(s):

Alex Adams ◽

Bodvar Ymisson ◽

Virginia Davies

Keyword(s):

Time Delay ◽

Safety Issue ◽

Discharge Summary ◽

Baseline Survey ◽

Key Factors ◽

Notification System ◽

Team Meetings ◽

Patient Safety Issue ◽

Technical Issues ◽

Electronic Discharge Summary

AimsAll patients discharged from our Paediatric Liaison Team will have an electronic discharge summary sent to their GP within 24 hours by January 2020.BackgroundWriting a GP discharge summary is an essential part of patient care and is a patient safety issue if not completed on time. The NHS England Standard Contract states discharge summaries should be completed and sent to a GP within 24 hours of discharge. Baseline data showed our median time between discharge and a GP summary being sent off as 3 days and a baseline survey of staff in our team rated our discharge summary process as inefficient and time consuming. At baseline our discharge summary was typed on a word document which was then emailed to admin staff who would print and post to the GP. Our electronic patient record had an inbuilt discharge notification function that generates and sends summaries via email to the GP that other teams in the trust were already using.MethodWe utilised the Model for Improvement Quality Improvement methodology. Initially we created a driver diagram breaking the process of discharge summary writing into its constituent components to generate change ideas. We then tested out these out in plan, do, study, act (PDSA) cycles whilst continually collecting data using a shared team spreadsheet to monitor for change.ResultWe found that switching to electronically sent discharge notifications improved our time from discharge to a summary being sent to the GP from a median of 3 days to 1 day. We noticed that alongside a shared team spreadsheet monitoring when summaries were written we also reduced variation of time between discharge and a summary from a range of 0-27 days (with an outlier of 161) to 0-9 days.ConclusionOn average the time from discharge to a summary being written met the standard and we reduced the variability of time delay by using an electronic notification. However only 56% of summaries were sent within the 24 hour limit. Key factors for continued variability identified during regular team meetings included overall caseload of patients, amount of staff on shift and technical issues with the form. Our plan for sustainability is to discuss monthly in the team meeting any discharges that took longer than 1 day and target further PDSA cycles to these issues.

Download Full-text