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Discharge Summaries Grossly Inadequate at Documenting Pending Test Results

Posted Sep 27 2009 10:34pm
A study in the September edition of the Journal of General Internal Medicine found that " discharge summaries are grossly inadequate at documenting both tests with pending results and the appropriate follow-up providers."

The study found that only 13% of discharge summaries document all pending tests. And only 25% of discharge summaries mention some pending tests. Follow-up providers information was included in 67% of discharge summaries. "The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return." The study evaluated discharge summaries at two academic medical centers for patients that had pending test results.

This adds to the communication challenges referring physicians face coordinating care in follow-up to a hospital visit. Yet communications issues are accountable for over half of all preventable errors. And communications issues are twice as likely to be related to deaths as compared to "clinical inadequacy".

The study reported that approximately 41% of patient are discharged with pending test results and 9% of these test results affect patient care management.
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