You developed the following discharge summary sheet. which critical information should you add?

Dr. Lenert is professor, Departments of Biomedical Informatics and Internal Medicine, and associate chair for Quality and Innovation, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.

Find articles by Leslie A. Lenert

Farrant H. Sakaguchi

Dr. Sakaguchi is a post-doctoral fellow, Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah.

Find articles by Farrant H. Sakaguchi

Charlene R. Weir

Dr. Weir is associate professor, Department of Biomedical Informatics, University of Utah School of Medicine, and associate director of the Veterans Affairs Health System Geriatric Research, Education, and Clinical Center and Salt Lake City Informatics, Decision Enhancement and Surveillance, Salt Lake City, Utah.

Find articles by Charlene R. Weir

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Leslie A. Lenert, Dr. Lenert is professor, Departments of Biomedical Informatics and Internal Medicine, and associate chair for Quality and Innovation, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.

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Correspondence should be addressed to Dr. Lenert, Department of Biomedical Informatics, University of Utah, 26 S 2000 E, Suite 5700, Salt Lake City, UT 84112-5750; telephone: 801-581-4080; [email protected]

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Abstract

The discharge summary is one of the most critical documents in medical care settings, but it is prone to systematic lapses that compromise the continuity of care. Discontinuity is fostered not only by incomplete inclusion of data (such as pending labs or medication reconciliations) but also by failure to document clinical reasoning and unfinished diagnostic workups. To correct these problems, the authors propose the Situation-Background-Assessment-Recommendation (SBAR) format for discharge summaries. SBAR is already used for handoffs the way Subjective-Objective-Assessment-Plan is for progress notes. The SBAR format supports the concise presentation of relevant information along with guidance for action. It shifts the paradigm and purpose of the discharge summary away from being a “Captain’s Log” (a historical record of the events, actions taken, and their consequences during hospitalization) towards being a handoff document (a tool for communication between health professionals aimed at insuring continuity of care.) To test SBAR as a template for discharge summaries, the authors have initiated a study to document the impact of the SBAR model on the quality of trainees’ thinking in discharge summaries.

In an academic setting, the purpose of medical note writing goes beyond documentation, payment facilitation, and communication. Note writing teaches residents and medical students how to think and also makes their thought process transparent, which helps in assessing their performance and tailoring education. Effective communication specifically requires addressing the higher levels of cognitive processing and synthesis. One widely used aid to help clinicians organize their thoughts while writing notes is the SOAP (Subjective Objective Assessment and Plan) template. However, this template is not well suited to discharge summaries because it has a focus differential diagnosis rather than on continuity of care and on deliberation rather than communication. How can we help residents and students “think better” at the end of an episode of care for a patient, the way the SOAP templates help them think better at the beginning and middle?

In this perspective, we argue for the “Situation-Background-Assessment-Recommendations” (SBAR) model as an effective framework for discharge summaries. We begin with a discussion of the current inadequacies of the “usual” method for creating discharge summaries. We then consider how handoff communication can be applied to thinking about the discharge summary, and we describe the SBAR model as a template for discharge summaries. We conclude with our plan for next steps in evaluating and validating the efficacy of the SBAR template.

Inadequacies of the Traditional Discharge Summary

The discharge summary is one of the most critical documents in medical care settings. The effects of its absence perhaps best define its importance: delayed discharge summaries are associated with a substantially increased risk of hospital readmission by 50% or more., Inadequate communications and deficiencies in information transfer at discharge—problems that might be addressed by a high quality discharge summary—are a frequent cause of errors and near misses.– O’Leary and colleagues found that 41% of outpatient general internists thought that at least one of their patients in the past six months had experienced a preventable adverse event due to poor transfer of information at discharge.

Many problems associated with inadequate discharge summaries can be viewed as a failure to organize the information at the level of abstraction required for good communication and narrative. For example, one of the most common problems with discharge summaries is the failure to include information on diagnostic tests that are still pending at discharge. Identifying pending tests requires awareness that others in the future will need this information. Were and colleagues found only 16% of tests pending at discharge were reported in discharge summaries, and only 67% of the discharge summaries adequately identified an outpatient provider to whom lab results could be sent. Walz and colleagues found that while a third of patients were discharged to sub-acute care with pending microbiology results, only a third of those pending results were documented in the discharge summaries. Roy and colleagues prospectively collected data on test results pending at the time of discharge from inpatient care and surveyed primary care physicians about the importance of these results. Lab results were pending for 41% of the patients, yet 61.6% of the time the primary care providers were unaware of those outstanding results, 9.4% of which were ultimately considered potentially actionable.

Discharge summaries also often fail to include critical recommendations from hospitalization for future actions. Moore and colleagues noted that 54.1% of all discharge summaries failed to describe the recommended outpatient workups that were clearly documented in the inpatient charts. In a review of discharge summaries at our own institution, we found that while changes in medication between outpatient and inpatient environments were documented—so-called medication reconciliation—the rationale for changes was almost never completely explained. Further, discharge summaries rarely discussed insights into patients’ preferences or the lessons learned for future care.

Why is it so common to omit critical information from discharge summaries, particularly information on higher-level thinking for patient management? Among the possible reasons such as time pressure, cognitive overload, and a lack of training is a problem we call the “Captain’s Log” phenomenon. In the “Captain’s Log” phenomenon, Rather than producing a document for another clinician taking over the care of the patient, physicians’ may be much more focused on producing a narrative story of what they believe are the salient features of a hospitalization, rather than producing a document for another clinician taking over the care of the patient. According to this hypothesis, physicians create summaries for themselves, under the constraint of organizational requirements for content (for example, hospital bylaws and the regulations accreditation bodies), as a process of sense-making through story telling. The discharge summary was developed in an era when it was traditional for primary care physicians to follow their patients into the hospital for care. At the time it may have been appropriate to simply summarize care rendered during the stay because there was no handoff—while the setting of care changed (hospital to clinic), the care provider did not. However, the value of the contemporary discharge summary as a historical document is questionable. In fact, Moore and colleagues found "information errors" between inpatient notes, the discharge summary, and the outpatient record in half of cases reviewed.

The “Captain’s Log” phenomenon occurs when communicators fail to adequately consider the perspective of the “other.” Psychological studies demonstrate that speakers are unaware of how poorly they communicate information. Accordingly, physicians fail to write the discharge summary at the level of clarity or synthesis required for effective communication. In one study of handoffs among pediatric interns, the most important information was missing 60% of the time, despite their belief that they were communicating well.

The complexity of the information may also thwart effective summarization and communication of data and priorities; the underlying problem is information overload. Discharge summaries include so many individual items, tests, and changes in therapy that the complexity of information may make it difficult for a person to remember all the significant items, let alone create a cohesive narrative. The author of the discharge summary strives to convey information for the handoff, but the task may be too complex for most humans to complete without checklist or a software tool that supports their cognition.

The hectic clinical environment in which discharge summaries are written also contributes to cognitive overload as there is usually significant time pressure and concurrent demands. In addition to causing slips or errors of omission, information overload also diminishes the capacity to imagine the perspective of the reader or the “other,” thus exacerbating the “Captains Log” phenomenon. Taking an alternative point-of-view in document creation requires considerable cognitive effort that only significant training would make automatic or natural.

Most prior work to solve the poor quality of discharge summaries has assumed that omission of critical information is due to information overload. Common strategies to mitigate overload have included checklists and electronic forms to prevent omissions from discharge summaries.– Investigators have demonstrated that such software can improve both the completeness and timeliness of discharge summaries.,, However, this approach does not fix problems with omission of higher-level types of information, such as workup plans, clinical goals, and lessons learned. This type of information is difficult for computers to extract from electronic health record (EHR) systems. Moreover, in educational settings, if a computer generates the summary for a patient, the resident or the medical student who used an EHR function may not have the opportunity to learn by actively deciding what information to include. A human role may be critical in training environments to teach the skills required for summarization; effective communication in a discharge summary requires a balance among completeness, clarity, and brevity.,

The Discharge Summary as a Handoff Communication

How can residents and students overcome the Captain’s Log mentality? We believe they need to recognize the discharge summary as a handoff, a specialized form of communication. Handoffs can be defined as the passing and accepting of information and responsibility for a patient from one provider to another. Herbert Clark, the communication theorist, would call it a “joint action”. Most clinicians are familiar with handoffs that occur during shift changes or when sharing call., –

The Institute of Medicine has identified failed communication as the most common cause of error in clinical settings. Many studies have found communication errors were involved in most – anywhere from 50% to 91%. – adverse events or “mishaps,” , According to theorists, shared knowledge regarding the goals, sense of the situation and roles of the other are central to effective communication. Medical school curricula have incorporated communication skills training for addressing physician-patient interaction, but have not yet expanded that teaching to writing progress notes and discharge summaries. However, recent qualitative work addressing perceptions of the impact of computerized documentation has found that clinicians may be starting to view electronic documents as a shared space, more in line with the view that clinical documentation is a form of communication.

SBAR—“Situation-Background-Assessment-Recommendations” —is the most commonly cited mnemonic for medical handoffs. We are studying its use as a cognitive tool to help physicians view the discharge summary as a handoff. Similar to the SOAP, SBAR provides a framework for the processes of communication, nudging the speaker to convey the overall “story” of the patient, to include goals and expectations, providing pertinent details as well as the big picture. Advocates of this model have argued that SBAR reporting promotes collaboration through communication of critical thought processes.

Historically, SBAR was used in the U.S. Navy to facilitate handoffs in nuclear submarines and improve communication from junior to senior officers., Since then, many groups, institutions, and programs have adopted the SBAR model; these include the Agency for Health Care Research and Quality’s Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program and their Patient Safety Network, the U.S. Department of Defense’s Patient Safety Program, the Institute for Healthcare Improvement, Kaiser Permanente, the National Health Service in the United Kingdom, and Interventions to Reduce Acute Care Transfers (INTERACT) collaborative., – Experience with using SBAR templates for handoffs suggests that it is a useful communications framework with positive effects on both individuals and organizations. Several observational studies have shown that adoption of SBAR templates for handoffs improved communications among interdisciplinary teams and enhanced perceptions of an organizational culture of safety.,– Additionally, Vardaman and colleagues observed that use of the SBAR format in handoffs enhanced rapid sharing of clinical contexts, clarified roles and expectations, and increased trust among interdisciplinary team members. The SBAR model also has been shown to facilitate critical thinking and analysis in case discussions in morbidity and mortality conferences.,

The SBAR Model for Discharge Summaries

How can the SBAR model be adapted to discharge summaries? In Figure 1, we mapped the common discharge summary components and applied them to a framework, which contains five sections: Header, Situation, Background, Assessment, and Recommendation. The “Header” section identifies the individuals and dates for the episode of care involved in the handover as the parameters for the transition of care. The patient, discharging, and follow-up physicians are explicitly identified since they are the key participants in the transition. The “Situation” section briefly describes the patient and his or her location within the current episode of care to help the reader understand the clinical and social context of the handoff. In addition to pending results and follow-up tests and appointments, concerns for readmission and interim care should be described in this section. “Background” provides a context for follow-up care such as relevant pieces of the hospital course. Procedures, vital signs, and other objective data in this section should not only provide a baseline, but also describe the trajectory of the patient. In the “Assessment” section, primary discharge diagnoses, chronic diagnoses, and the patient’s condition should be systematically listed as necessary to meet institutional requirements for documentation. The “Recommendations” section emphasizes medical reasoning for future medical care, addressing the bulk of the standard discharge summary’s inadequacies. Patients’ preferences, such as code status and advanced directives, which should appear in this section, ensure that those preferences guide future care. Additionally, unresolved issues or uncertain diagnoses should be discussed. Finally, the Recommendations Section should explicitly indicate which medications have been discontinued, changed or added during hospitalization (e.g., medication reconciliation) along with a rationale for the changes.

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Figure 1

Restructured into the SBAR format, discharge summaries can still meet all The Joint Commission’s requirements for discharge summaries. For examples of SBAR-formatted discharge summaries, see [LWW INSERT LINK].

Changing the discharge summary’s format from summarization to a handoff model would shift its focus to collaborative care and the next provider. Too often, discharge summaries give great detail regarding the hospital stay, yet provide minimal useful information to outpatient providers who see the patient for follow-up. Instead of a historical summary, discharge summaries should contain a strategic plan for future care. Lessons learned and unresolved issues from the hospitalization would be discussed. In addition, discharge summaries would include a projection (i.e. a prediction) of how the author believes patients’ clinical condition will evolve over time. For example, if a patient is discharge on oxygen therapy: “we believe that oxygen therapy will be able to be weaned within 1–2 weeks.” With the SBAR framework, the author of a discharge summary would need to think about continuity of care, communicate medical reasoning and identify the factors necessary to convey situation awareness of the medical status of the patient, including relevant preferences and contextual information.

Evaluating SBAR’s Impact and Next Steps

Proving that SBAR templates will improve residents’ ability to create effective discharge summaries is a difficult task. We cannot directly compare the quality of the thinking in discharge summaries that were created using an SBAR template versus the standard format because the summary’s SBAR structure would un-blind raters, creating potential biases. To overcome this problem, we plan to interview residents after they have completed their discharge summaries, to capture their thought processes about the patient. Each resident will provide an oral handoff summary of the case. A blinded independent rater will rate the degree of organization of the resident’s thinking and we will compare the degrees of organization observed between use of the SBAR model and the standard template.

We hypothesize that the SBAR template will elevate residents’ thinking to a higher level of reasoning or synthesis based on Hollnagel’s Contextual Control model. We define the thinking pattern, ranging from “scrambled” to “strategic” levels, by the degree to which discharge summaries contain actual plans for the care of patients in the community and the extent to which those plans take into account the non-medical contexts surrounding the patient’s care (see Table 1).–

Table 1

Approach to Analyzing the Quality of Thinking in Discharge Summaries, adapted from Hollnagel’s Contextual Control Model*

LevelDescriptionStrategicClear, patient-centered narrative that includes goals, priorities, relationships, choice of actions, reasoning and predicted outcomes.TacticalAdequate narrative that may include goals, priorities, relationships, but tends to demonstrate a reliance on guidelines or scripts. Supportive reasoning may not be present.OpportunisticDisconnected narrative that identifies a few goals, but minimal identification of priorities or patient perspective. Lacks reasoning and integration of predicted outcomes.ScrambledIncoherent narrative with no identifiable priorities for goals or patient perspective. Lacks reasoning and predicted outcomes.

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*See Hollnagel 2005

Integrating SBAR and Informatics

As we study the impact of the SBAR format for discharge summaries, we are not proposing to abandon work on informatics systems that address information overload by including data already in the EHR. Instead, a well-implemented system will refocus the clinician’s cognitive energy on communicating reasoning, goals and recommendations and future priorities for care. Rather than simply producing lists of diagnoses, procedures, labs, and medications, or recounting a historical narrative of the events of hospitalization, an advanced SBAR discharge summary application will facilitate the creation and telling of a different type of narrative from the hospitalization—stories that facilitate the return of the patient to management in an ambulatory environment. This task is inherently different from the summarization of successes and failures in a Captain’s Log. The emphasis, particularly for clinicians in training, will be on identifying and sharing the lessons learned in the acute hospital setting, to provide a strategic background for the future longitudinal care of the patient.

Supplementary Material

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Acknowledgements

The authors thank Kurt Barsch, MS for useful discussions and Beth Sakaguchi, MA for reviewing the manuscript’s readability.

Funding/Support: Dr. Sakaguchi is supported by the National Library of Medicine Training Grant No. T15LM007124.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Other disclosures: None reported.

Ethical approval: Reported as not applicable

Contributor Information

Leslie A. Lenert, Dr. Lenert is professor, Departments of Biomedical Informatics and Internal Medicine, and associate chair for Quality and Innovation, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.

Farrant H. Sakaguchi, Dr. Sakaguchi is a post-doctoral fellow, Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah.

Charlene R. Weir, Dr. Weir is associate professor, Department of Biomedical Informatics, University of Utah School of Medicine, and associate director of the Veterans Affairs Health System Geriatric Research, Education, and Clinical Center and Salt Lake City Informatics, Decision Enhancement and Surveillance, Salt Lake City, Utah.

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