Page 13 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Discharge Instructions and Educational

Materials

The use of discharge or clinical visit summaries and computer-

assisted educational materials can save time and reduce
miscommunication about follow-up instructions. Document any

education materials provided to the patient. Carefully document

your discharge instructions, noting the communication processes

employed to establish patient understanding. This could include a

post-encounter visit summary, techniques such as “read-back” and
instructions given to those accompanying the patient. Include the

main points discussed during the encounter. Include the specific

warning symptoms that should provoke a follow-up contact.

Utilizing a standardized format or template to convey the key

points from the visit or hospitalization can improve documentation.

A 3-year study at a community teaching hospital found that the
use of a template while dictating discharge summaries improved

the average quality of the summaries by 21% while reducing the

average dictation time by 67%. This study also emphasizes that the

quality of documentation—as measured by the usefulness of the

information provided—is more important than the quantity.
2

What Should Not be Documented/Maintained

in the Medical Record

Incident reports or other non-patient care information should not

be included in the medical record. Only clinically pertinent incident

related information should be entered in the patient record. Billing

2 Rao P, Andrei A, Fried A, Gonzalez, D, et al. Assessing quality and efficiency of discharge summaries. Am J
Medical Qual 2005;20:337-43
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