Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria

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.


| INTRODUCTION
In order to ensure that patients are safely discharged from the hospital, the medical discharge summary (DS) represents one of the most important instruments to summarize all patient-relevant medical information. Incomplete and inaccurate medical DS (important contents are not displayed, spelling mistakes, ambiguous wording, etc.) can lead to severe problems including an increase in the risk of re-admission 1,2 and thus represent a barrier to efficient health services. [3][4][5] Several issues related to the medical DS have already been identified. 6 Delayed transmission of the DS to the further treating physician, [7][8][9] low quality or lack of information, 10,11 lack of consistent formats, [12][13][14] lack of patient understanding, 15,16 and inadequate training for medical students in writing medical DS 17 are some important issues. The medical DS is not only an important document for the treating general physician (GP) but it is also relevant for other healthcare providers as well as patients and relatives. 18 The use of specific medical jargon and unexplained abbreviations of medical terms hinder effective communication with all involved parties and cause relevant information to go unnoticed. [18][19][20][21][22] According to Austrian law every patient must receive a DS at discharge and patients are owners of the written DS. 23 In general, international studies have also reported that errors and unknown abbreviations in DS are often causing ambiguities. 21,24 DS with a summary in plain language support patients and relatives in understanding important information (eg, further recommended measures, medication intake). 25 While it is mandatory in Austria to have a DS at discharge, there are currently no national standards regarding a unified structure. Every hospital is currently using a different structure which has often been criticized by GPs.

| Development of a Case Report Form (CRF)
A CRF was created to systematically review the DS (see Data S1). The items in the CRF were based on the results of a literature search in PubMed which identified a total of 209 key components of medical DS and the CRF also included the mandatory and optional headings of ELGA.
The mandatory and optional headings of ELGA are presented in Table 1.
The CRF was pre-tested by several experts (nurses, physicians, and staff from the quality and risk management department) and all five reviewers, each using two DS (from different medical disciplines: surgery and internal medicine). With the pre-test results, all reviewers were trained regarding the use of the CRF and the scoring using the Likert-type scale. .004 ELGA headings (Data S1) and scored using the Likert-type scale.

| Content of the CRF
Each DS was reviewed by at least two independent reviewers.
The reviewers individually scored each item on a 4-point Likert-type scale from "strongly agree" to "strongly disagree", with the additional option of "not relevant". After the individual scoring process, results were compared and discussed between the two reviewers. If there was a disagreement, a third reviewer was involved and the final scoring represents a consensus decision.

| Statistical analysis
Data was descriptively analysed using absolute and relative frequencies. Missing data and "not relevant" are explicitly displayed in the results. Fisher's exact test with a significance level of 0.05 was used to compare the medical disciplines. "Not relevant" scores were considered missing for these analyses. The analyses were performed using R version 3.6.1. 28

| RESULTS
In total, 100 DS from five clinics were evaluated: internal medi-

| Use of mandatory ELGA headings
The mandatory items according to ELGA that have to be covered in the DS include: reason for admission, diagnosis at discharge, last/recommended medication, and further recommended measures. The reason for admission was scored as "strongly agree" in 80% of DS, and diagnosis at discharge was fully scored in 98% of DS. Further recommended measures were fully scored in 62% of the DS. Detailed results are presented in Table 2.
According to ELGA, the "last medication" given in the hospital must be specified in case of a discharge to other hospitals or institutions, whereas the section "recommended medication" must be indicated in case of a discharge to a GP or specialist.
The last medication was scored fully ("strongly agree") in 48% and the recommended medication in 94% of respective DS. The dose or concentration of the last medication was indicated in 11% of DS. Furthermore, the dosage form and method of administration was described in 13% of DS and the administration interval was presented in 7% of DS.
Regarding the recommended medication, the name of the drug was present in 88% of DS. The dose and concentration of the recommended medication was outlined in 75% of DS, whereas the dosage and method of administration was noted in 23% of DS. Detailed results see Table 2.

| Differences between clinics
We examined differences among five medical disciplines regarding their use of mandatory DS headings. We found significant overall differences among clinics for nine mandatory headings: reason for admission (P < .001); last medication (P < .001); appointments, control (P = .002); discharge condition (P = .012); recommended arrangements for further care (P < .001); full name of the drug (last medication) (P < .001); frequency of administration (last medication) (P = .004); dosage form or method of application (recommended medication) (P < .001); frequency of administration (recommended medication) (P < .001). Statistically significant results are presented in Table 3 and all results are displayed in Data S2.
A post hoc analysis revealed which clinics differed significantly from each other regarding each mandatory heading (see Data S3).

| Use of abbreviations in the DS
In total, 750 different abbreviations were found in the 100 evaluated DS. The 100 most common abbreviations are presented in Table 4. The following pre-processing steps were carried out on the raw data as an attempt to catch and combine different spellings of the same abbreviation: lower/upper case was ignored, blank spaces were removed, points at the end of an abbreviation were ignored, commas were replaced by dots (to catch any commas used as a decimal separator).

| Use of mandatory headings in sampled DS
Our analysis showed that some items of the DS had always higher scores than others. Mandatory fields (according to ELGA) such as reason for admission, diagnosis at discharge, and recommended medication were present in all 100 evaluated DS and content was largely complete. However, some optional yet important items, such as for example, details on medication, were often lacking.
Physicians previously agreed on including important items such as diagnosis (100%), therapy (99.7%), recommendations on further treatment (99.6%), prescription of medication (98.5%), as well as behavioural recommendations for patients (94.4%). 18 This important information could be more easily structured and be immediately available with the implementation of electronic health records. Using electronic health records could also more easily improve the structural quality of DS, albeit not the use of abbreviations in text boxes and the resulting low comprehensibility.

| Description of medication
We found that only few of the evaluated medical DS included specific details about the medication that was last given at the hospital or about further recommended medication. Accuracy and completeness of patients' medication information in the DS and notation of any changes are very important items to ensure patient safety and continuity of care. Previous studies found that as much 11% of patients' medication documentation showed discrepancies at discharge 32 and that a quality improvement of DS resulted in fewer medication errors per patient. 10 Since medication errors due to incomplete DS have the potential to cause serious harm to patients, the recommended medication after discharge is important to ensure that further treatment is safe and effective. The use of electronic DS has the potential to reduce discharge medication errors. 33 "Humanalbumin", "Hämagglutinin" or "Hyaluronan". Bechmann found that more than 50% of surveyed GPs stated that DS generally contain too many abbreviations, and 71% of the surveyed GPs felt that unknown abbreviations can usually not be deduced from the context.
Nearly all respondents (94%) had to look up abbreviations either frequently or occasionally. 36

ACKNOWLEDGEMENTS
We would like to thank everyone who contributed to the study.
Especially, we would like to thank the Department of Finance and

PATIENT CONSENT FOR PUBLICATION
Not required.

ETHICS APPROVAL
The Ethics Committee of the Medical University of Graz approved the study (vote#: 29-338 ex16/17).

CONSENT FOR PUBLICATION
All authors confirmed the publication in its present form.

TRANSPARENCY DECLARATION
The lead authors (C.M.S., M.H.) affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

DATA AVAILABILITY STATEMENT
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.