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Yahalom S, Manias E. Nurses engaging with referral letters and discharge summaries: A qualitative study. J Clin Nurs 2024; 33:2309-2323. [PMID: 38304996 DOI: 10.1111/jocn.17054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 12/30/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
AIMS To investigate the ways that nurses engage with referral letters and discharge summaries, and the qualities of these documents they find valuable for safe and effective practice. DESIGN This study comprised a qualitative, case-study design within a constructivist paradigm using convenience sampling. METHODS Interviews were conducted with nurses to investigate their practices relating to referral letters and discharge summaries. Data collection also involved nurses' examination and evaluation of a diverse range of 10 referral letters and discharge summaries from medical records at two Australian hospitals through focus-group sessions. The data were transcribed and analysed inductively. RESULTS In all, 67 nurses participated in interviews or focus groups. Nurses indicated they used referral letters and discharge summaries to inform their work when caring for patients at different times throughout their hospitalisation. These documents assisted them with verbal handovers, to enable them to educate patients about their condition and treatment and to provide a high standard of care. The qualities of referral letters and discharge summaries that they most valued were language and communication, an awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. CONCLUSION Nurses relied on referral letters and discharge summaries to ensure safe and effective patient care. They used these documents to enhance their verbal handovers, contribute to patient care and to educate the patient about their condition and treatment. They identified several qualities of these documents that assisted them in maintaining patient safety including clarity and conciseness of information. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE It is important that referral letters and discharge summaries are written clearly, concisely and comprehensively because nurses use them as key sources of evidence in planning and delivering care, and in communicating with other health professionals in relaying goals of care and implementing treatment plans. IMPACT Nurses reported that they regularly used referral letters and discharge summaries as valuable sources of evidence throughout their patients' hospitalisation. The qualities of these documents which they most valued were language and communication styles, awareness of audience and clinical knowledge, as well as balancing conciseness with comprehensiveness of information. This research has important impact on the patient experience in relation to encouraging effective referral letter and discharge summary writing. REPORTING METHOD We have adhered to the relevant EQUATOR guidelines through the SRQR reporting method. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Sharon Yahalom
- Faculty of Medicine, Nursing and Health Sciences, Student Academic Support Unit, Monash University, Melbourne, Victoria, Australia
- Faculty of Arts, School of Languages and Linguistics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Manias
- Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
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Mohd Sulaiman I, Bulgiba A, Abdul Kareem S. Prevalence and Risk Factors for Dangerous Abbreviations in Malaysian Electronic Clinical Notes. Eval Health Prof 2023; 46:41-47. [PMID: 36444613 DOI: 10.1177/01632787221142623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where English is widely used, and elicit the risk factors associated with dangerous abbreviations. We randomly sampled and manually annotated 1102 electronic discharge summaries for abbreviations and their senses. Three medical doctors assigned a danger level to ambiguous abbreviations based on their potential to cause patient harm if misinterpreted. The predictors for dangerous abbreviations were determined using binary logistic regression. Abbreviations accounted for 19% (33,824) of total words; 22.6% (7640) of those abbreviations were ambiguous; and 52.3% (115) of the ambiguous abbreviations were labelled dangerous. Increased risk of danger occurs when abbreviations have more than two senses (OR = 2.991; 95% CI 1.586, 5.641), they are medication-related (OR = 6.240; 95% CI 2.674, 14.558), they are disorders (OR = 7.771; 95% CI 2.054, 29.409) and procedures (OR = 3.492; 95% CI 1.376, 8.860). Reduced risk of danger occurs when abbreviations are confined to a single discipline (OR = 0.519; 95% CI 0.278, 0.967). Managing abbreviations through awareness and implementing automated abbreviation detection and expansion would improve the quality of clinical documentation, patient safety, and the information extracted for secondary purposes.
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Affiliation(s)
- Ismat Mohd Sulaiman
- Health Informatics Centre, Planning Division, 26691Ministry of Health Malaysia, Malaysia
| | - Awang Bulgiba
- Centre for Epidemiology and Evidence-based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, 37447University of Malaya, Malaysia
| | - Sameem Abdul Kareem
- Department of Artificial Intelligence, Faculty of Computer Science and Information Technology, 37447University of Malaya, Malaysia
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Schwarz CM, Hoffmann M, Smolle C, Eiber M, Stoiser B, Pregartner G, Kamolz LP, Sendlhofer G. Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria. J Eval Clin Pract 2021; 27:1243-1251. [PMID: 33421263 PMCID: PMC9290607 DOI: 10.1111/jep.13533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 01/03/2023]
Abstract
RATIONALE AND OBJECTIVE The discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations. METHOD One hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4-point Likert-type scale ranging from "strongly agree" to "strongly disagree" (or "not relevant"). Subsequently, the results were discussed among reviewers to achieve a consensus decision. RESULTS The mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS. CONCLUSIONS In conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations.
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Affiliation(s)
- Christine Maria Schwarz
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Magdalena Hoffmann
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Executive Department for Quality and Risk Management, University Hospital Graz, Graz, Austria.,Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christian Smolle
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Michael Eiber
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Bianca Stoiser
- Department of Management, Health Management in Tourism, University of Applied Sciences, Bad Gleichenberg, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics und Documentation, Medical University of Graz, Graz, Austria
| | - Lars-Peter Kamolz
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gerald Sendlhofer
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Executive Department for Quality and Risk Management, University Hospital Graz, Graz, Austria
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Coghlan A, Turner S, Coverdale S. Danger in discharge summaries: Abbreviations create confusion for both author and recipient. Intern Med J 2021; 53:550-558. [PMID: 34636114 DOI: 10.1111/imj.15582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/26/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The transition from hospital inpatient care to medical care in the community is a high-risk period for adverse events. Inadequate communication, including low quality or unavailable discharge summaries, has been shown to impact patient care. AIMS Assess use of abbreviations in clinical handover documents from inpatient hospital teams to general practitioners (GPs), and the interpretation of these abbreviations by GPs and hospital-based junior doctors. METHODS Retrospective audit of 802 discharge summaries completed during a one-week period in 2017 by a Queensland regional health service. GPs and local junior doctors then attempted interpretation of twenty relevant abbreviations. RESULTS 99% (794) discharge summaries included abbreviations. 1612 different abbreviations were used on 16 327 occasions. The median number of abbreviations per discharge summary was 17 (range 0-86). 254 GPs and 62 junior doctors responded to a survey which found that no abbreviation was interpreted the same by all respondents. GPs and junior doctors were unable to offer any interpretation in 17.9% and 15.2% of cases respectively. GPs offered a greater range of interpretations than junior doctors, with a median of 9 and 3 different interpretations per abbreviation respectively. 94% (239) of GPs felt that the use of abbreviations in discharge summaries had the potential to impact patient care. 152 (60%) GPs felt that time spent clarifying abbreviations in discharge summaries could be excessive. CONCLUSIONS Abbreviations are often used in discharge summaries, yet poorly understood. This has the potential to impact patient care in the transition period after hospitalisation This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anna Coghlan
- Sunshine Coast Hospital and Health Service, 6 Doherty St, Birtinya QLD AUS 4575.,Fernlands Radius Medical Centre, 10 Woodhill Road, Ferny Hills QLD AUS 4055.,University of Queensland Faculty of Medicine, Herston QLD AUS 4006, Australia
| | - Sophie Turner
- Sunshine Coast Hospital and Health Service, 6 Doherty St, Birtinya QLD AUS 4575.,Metro North Hospital and Health Service, 7 Butterfield St, Herston QLD AUS 4006, Australia.,University of Queensland Faculty of Medicine, Herston QLD AUS 4006, Australia
| | - Steven Coverdale
- School of Medicine, Sunshine Coast, Griffith University, 6, Doherty St, BIRTINYA, QLD 4575, Australia
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Grossman Liu L, Grossman RH, Mitchell EG, Weng C, Natarajan K, Hripcsak G, Vawdrey DK. A deep database of medical abbreviations and acronyms for natural language processing. Sci Data 2021; 8:149. [PMID: 34078918 PMCID: PMC8172575 DOI: 10.1038/s41597-021-00929-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/27/2021] [Indexed: 12/05/2022] Open
Abstract
The recognition, disambiguation, and expansion of medical abbreviations and acronyms is of upmost importance to prevent medically-dangerous misinterpretation in natural language processing. To support recognition, disambiguation, and expansion, we present the Medical Abbreviation and Acronym Meta-Inventory, a deep database of medical abbreviations. A systematic harmonization of eight source inventories across multiple healthcare specialties and settings identified 104,057 abbreviations with 170,426 corresponding senses. Automated cross-mapping of synonymous records using state-of-the-art machine learning reduced redundancy, which simplifies future application. Additional features include semi-automated quality control to remove errors. The Meta-Inventory demonstrated high completeness or coverage of abbreviations and senses in new clinical text, a substantial improvement over the next largest repository (6–14% increase in abbreviation coverage; 28–52% increase in sense coverage). To our knowledge, the Meta-Inventory is the most complete compilation of medical abbreviations and acronyms in American English to-date. The multiple sources and high coverage support application in varied specialties and settings. This allows for cross-institutional natural language processing, which previous inventories did not support. The Meta-Inventory is available at https://bit.ly/github-clinical-abbreviations. Measurement(s) | Controlled Vocabulary • Linguistic Form | Technology Type(s) | digital curation • data combination | Sample Characteristic - Location | United States of America |
Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.14068949
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Affiliation(s)
- Lisa Grossman Liu
- Department of Biomedical Informatics, Columbia University, New York, NY, USA.
| | | | - Elliot G Mitchell
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - Karthik Natarajan
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - David K Vawdrey
- Department of Biomedical Informatics, Columbia University, New York, NY, USA.,Steele Institute for Health Innovation, Geisinger, Danville, PA, USA
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Design and preliminary evaluation of a newly designed patient-friendly discharge letter - a randomized, controlled participant-blind trial. BMC Health Serv Res 2021; 21:450. [PMID: 33975590 PMCID: PMC8114527 DOI: 10.1186/s12913-021-06468-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low health literacy has been associated with poor health outcome and impaired use of healthcare services. The hospital discharge letter represents a key source of medical information for patients and can be used to address the problem of low health literacy. The aim of this project was to develop and evaluate a new, patient-directed, version of the discharge letter. METHODS Based upon two conventional discharge letters (CDL; one surgical and one medical letter), two new, patient-friendly discharge letters (PFDL) were designed following 5 key principles: short sentences, few abbreviations, large font size, avoidance of technical terms and no more than 4 pages length. Medical undergraduates were randomized into two blinded groups (CDL, PFDL) and asked to assess the assigned letter for the 3 domains structure, content and patient-friendliness. Subsections were rated on a 6-point Likert scale (1 = completely agree, 6 = completely disagree), the results of the survey were compared using the Mann-Whitney-U-Test with a p < 0.05 being the level of significance. RESULTS In total, 74 undergraduates participated in this study. PFDL (35 participants) were rated significantly better than CDL (39 participants) regarding structure (median 1 vs. 2, p = 0.005), content (1 vs. 3, p < 0.001) and patient-friendliness (2 vs. 6, p < 0.001). Of all 17 subsections, PFDL were rated significantly better in 12 cases, and never worse than CDL. CONCLUSIONS PFDL were rated significantly better than their CDL counterparts. Medical undergraduates were considered the ideal cohort, not being medical lays and yet unbiased regarding everyday clinical practice procedures. Further tests evaluating the impact of the PFDL on patient comprehension and health literacy are necessary.
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Hoffmann M, Schwarz CM, Pregartner G, Weinrauch M, Jantscher L, Kamolz L, Brunner G, Sendlhofer G. Attitudes of physicians towards target groups and content of the discharge summary: a cross-sectional analysis in Styria, Austria. BMJ Open 2019; 9:e034857. [PMID: 31852713 PMCID: PMC6937118 DOI: 10.1136/bmjopen-2019-034857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The discharge summary (DS) represents one of the most important instruments to ensure a safe patient discharge from the hospital. They sometimes have poor quality in content and often include medical jargon, which the patient and their relatives cannot easily understand. Therefore, many risks for patient safety exist. This study investigated the questions for whom the DS is and which contents are necessary to ensure a safe treatment. DESIGN Cross-sectional analysis. SETTING Styria, Austria. PARTICIPANTS 3948 internal and external physicians were consulted. INTERVENTIONS An online survey consisting of 24 questions was conducted. The survey was distributed to physicians working in the province of Styria, Austria, in 2018 over a period of 6 months. MAIN OUTCOMES AND MEASURES Attitudes of internal and external physicians in terms of target group, content and health literacy. RESULTS In total, 1060 physicians participated in the survey. The DS is considered as a communication tool among physicians (97.9%) and the patients are also indicated as addressees (73.5%). Furthermore, there is a high level of agreement that understandable information in the DS leads to fewer questions of the patients (67.9%). CONCLUSION In conclusion, the DS is not only seen as a document for the further treating physician but is also relevant for the patient. Incorporating the patient into their treatment at all levels may possibly strengthen the individual health literacy of the patient and their caring relatives.
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Affiliation(s)
- Magdalena Hoffmann
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christine Maria Schwarz
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics und Documentation, Medical University of Graz, Graz, Austria
| | - Maximilian Weinrauch
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Lydia Jantscher
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
| | - Lars Kamolz
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gernot Brunner
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gerald Sendlhofer
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Rohr B, Berger A, Cotseones J, Hossler N, Hossler E. Understanding of abbreviations in dermatology: a survey of primary care providers. J Eur Acad Dermatol Venereol 2019; 33:e306-e308. [DOI: 10.1111/jdv.15586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- B.R. Rohr
- Department of Dermatology Geisinger Health System 16 Woodbine Lane Danville PA 17821 USA
| | - A. Berger
- Biostatistics Core Department of Biomedical and Translational Informatics Geisinger Health System 100 North Academy Avenue Danville PA 17822 USA
| | - J. Cotseones
- Department of Dermatology Geisinger Health System 16 Woodbine Lane Danville PA 17821 USA
- Department of Dermatology Northwestern Medicine 636 Raymond Drive Naperville IL 60563 USA
| | | | - E. Hossler
- Department of Dermatology Geisinger Health System 16 Woodbine Lane Danville PA 17821 USA
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Shilo L, Shilo G. Response to Jolobe: 'Medical abbreviations generate potentially dangerous ambiguity'. QJM 2018; 111:507. [PMID: 29648654 DOI: 10.1093/qjmed/hcy076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- L Shilo
- Department of Medicine "C", Meir Medical Center, Kfar Saba 52900 and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - G Shilo
- Department of Linguistics, Beit Berl College, Beit berl 4490500, Israel
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