Evaluating the Quality of Content and Degree of Completeness of Discharge Summaries from the Physicians' Perspective

Discharge summaries (DSs) are among the most important tools for transferring information from hospital physicians to other physicians and play an important role in the continuity of care. Low quality and lack of information are the main problems of DSs, and evaluation of their quality from the physicians' perspective in Iran has rarely been done. This study aimed to evaluate the DSs' quality of content and completeness.

This descriptive cross-sectional study was performed on the DSs of Shafa Hospital in Kerman. A valid and reliable researcher-made questionnaire (α=0.97) was used. This questionnaire had three sections, including questions related to demographic information, evaluation of the quality of DSs (8 questions), and the degree of completeness of the DSs (8 questions).

Out of 110 physicians, 98 (89%) filled out questionnaires. Completeness, awareness, continuity of care, legibility, relevancy, length, consistency, organization, and physicians’ satisfaction were below the average (50%) throughout the hospital. The highest level of physicians' satisfaction with the quality of the content (79.27%) and completeness (77.73%) was attributed to electronic discharge summaries of the neurology department. Organization, legibility, and consistency, respectively, were identified as the best predictors of physicians' satisfaction with the quality of the DSs’ content.

Policymakers should increase the quality of DSs by creating instructions, holding documentation training courses, increasing the supervision of senior physicians on interns and residents, and finally developing electronic automated DSs.