hospital discharge reports are not always complete as they should. In some cases, do not reflect the size or weight of patients, although the plan does not detail who should receive treatment after discharge from the hospital and often are written in a language unintelligible to the patient. This follows a study carried out by twelve learned societies, which has highlighted the need for a discharge report patient-oriented, says in this interview Javier Garcia Alegria, vice president of the English Society of Internal Medicine ( SEMI) and Chief of Internal Medicine, Hospital Costa del Sol in Marbella (Málaga).
scientific societies met to develop a joint study on hospital discharge reports. How is done?
The project has two parts. First, the English Society of Internal Medicine (SEMI) has proposed to establish uniform criteria to produce reports from the hospital. To this end, held a consensus conference attended by twelve learned societies, many of them specializing in hospital medicine, and three primary care societies, in addition to the Patient Forum. In this context produced a document which sets out the recommendations for discharge reports, which have been published this year in the journal "Clinical Medicine" for each scientific society the broadcast, so that the maximum possible number of doctors know how to write a report properly.
And the second part?
The other part consisted of a study on the quality of hospital discharge reports in four internal medicine outside hospitals Bellvitge (Barcelona), Gregorio Marañón (Madrid), Requena (Valencia) Costa del Sol (Marbella). We have analyzed more than 400 reports and up to 46 variables are considered in the consensus as "variable quality."
What results have been obtained? Have you identified gaps?
In general, despite reports of high quality are acceptable, there are some areas for improvement related to complete patient identification, date of birth, not age, or administrative data (address and telephone email) . We believe they have to improve the instructions are below 80% compliance, which is already high. However, there are more points to be improved: collecting physical examination data does not usually include height and weight, when it is highly recommended you use many acronyms and eponyms that the patient does not understand and do not always well reflected aspects of continuity of treatment, when to see the patient again, who will have to see and, moreover, suggest many abbreviations associated with therapy.
If a patient does not agree with his discharge report, can demand changes?
Yes, and you must ask your own doctor. One of the conditions of the consensus is that discharge report must be, in a clear, patient-oriented. legal regulations on how they should be these reports is the Ministry of Health and Social Policy and describes how sections should be given. But since we have tried to SEMI go further: we want to make improvements in their quality to make them more understandable to the patient.
Why is it so important that details the size and weight at discharge from hospital care?
Because they are objective and useful to administer a medication. It is an objective because, after leaving the hospital a person weighing 80 kilos and after two months weighs 72, we know for sure that he has lost weight. Nor must a lab result showing that a parameter is normal, we must point out a precise number because it can be important in the long term.
are fundamental data for other specialists.
Right. The problem of hospital discharge reports is that they have different users, in addition to the individual physician, other specialists, primary care physicians and emergency-the patient or their relatives. Therefore, in drafting the consensus document that interested us the perspective of the family doctor, as usual, has a limited time to read these reports and require very precise information. The data has to be oriented to also support their use.
As for the language used, must we make an effort to make it more understandable to the patient?
is a dilemma it is not easy to solve, because the language of science is based on accuracy. The spleen can only be called spleen. Among these limitations, we must try to reconcile the patient information and, specifically, the most important to him. Treatment should express, reflect and be complete, ie must be taken to show what, how, when and duration, in an understandable manner, and any other information that should be simplified, such as on diet, physical activity and follow-up, and whether to contact again, when and with whom, whether with a service of the hospital or your family doctor.
According to the study, the main victims of these reports are incomplete are patients with complex diseases. Why? There
older patients with multiple diseases that take many different drugs, which is a problem for the current health care system. It is therefore very important that the report expresses well what is the patient's functional status, quality of life, that is, how it is, and that explains well all the medications you take.
You mean the treatment plan?
Yes, the recommendations should be expressed about the situation the patient at the time of her discharge, while the treatment plan has to consider what diet to follow, why physical activity should be practiced, this aspect was not referenced in many of the reports evaluated, "what should be the full treatment should take, with the name of the drug well expressed, doses, schedules and new medications, monitoring the patient needs, deadlines and priority for revisions.
Why is it important for the patient to pay attention to the report of discharge? Because
admitted to a hospital is an important fact to change the patient's situation and perspective be admitted for a disease can be a traumatic event that changed life circumstances, personal and treatment of a person. Therefore, it is worth to read it and think that this report is a communication tool that does not avoid or limit the measure of the relationship between doctor and patient and must be accompanied by associated verbal information. Above all, the patient should keep it.
Interview: Clara Bassi
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