Aims We investigated general practitioners’ (GPs’) preferences for the information provided in discharge summaries as part of an initiative to improve and standardize our discharge summaries.
Method Our research methods included sending a questionnaire to all GPs in our area to gather their opinions on what information should be included in discharge summaries for first and subsequent inpatient episodes.
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Results, 68% of people responded. Most GPs desired a comprehensive first discharge summary, emphasizing the importance of practical information. Case histories may be excluded from subsequent discharge summaries.
Implications for Clinical Practice In contrast to previous studies that indicated a preference for brief reports, the GPs polled valued considerable detail in adult psychiatry discharge summaries. It is critical to consider these perspectives when developing auditing standards and making changes.
Adult psychiatric, communication, discharge, general practice, letter, primary healthcare, quality indicators, summary, and survey are some of the keywords.
Discharge summaries provide the link between secondary and primary care. The risk of readmission1 and adverse events such as medication errors have been linked to their quality. 2 Clinical audits of discharge summaries have focused on a variety of factors, including whether they were completed at all, three accuracies (errors of omission and commission), four conformity to a predetermined format,3,5 conformity to medication guidelines, six timeframes7, and receipt by the relevant general practitioner (GP). 4 These are usually self-evident standards.
Clinical auditing is an iterative process that involves comparing performance to a standard, identifying any shortfalls, devising and implementing a plan to eliminate or reduce the shortfall, and re-auditing to reassess performance against the standard. Many standards, such as the National Institute for Health and Clinical Excellence (NICE) guidelines or the British National Formulary, are easily accessible. In some cases, however, there is no clear standard, so a preliminary study is required. The current study is a pre-audit study that looks into the information in psychiatric discharge letters that GPs think is useful.
GPs receive a quick summary (usually an A4 proforma) and a longer prose letter. Although it is evident that items considered necessary for a brief, immediate summary, such as those reached by Essex et al. 8, will be expected to be included in a full letter, in some studies, it is unclear which document is referred to. 9
The psychiatric discharge letter (or summary) usually serves two purposes: for future reference within secondary care and to communicate with primary care. One study10 began with advice from psychiatrists for psychiatrists. Some studies have sought GPs’ opinions on the content and length of the discharge summary, but none appear to be recent. Separate documents for the two audiences have been advocated in some studies,10-12, but one study decided against it. 13
Anecdotally, psychiatrists are frequently told by non-GP staff that their discharge letters are too long and will not be read by GPs. Craddock and Craddock10 provided GPs with a choice of three different length formats (half A4, one side of A4, 2.25 sides of A4): 66% preferred the medium length, and 25% preferred the long length. A study using very similar methods produced nearly identical rates, except for a preference for longer letters for first-time admissions. 14 GPs considered approximately 50%13,15 to 30%7 of letters to be too long in three separate studies. Anderson and Kirby12 discovered that when GPs were routinely sent a summary with the option to request more detail, no GP requested more. Nonetheless, studies on the proportion of GPs who read the letters show a high proportion (85-98%). 7,15 A study aimed at streamlining letters discovered that some GPs lamented the loss of narrative. 16 There was little response when GPs were asked to suggest what could be usefully left out of letters. 13 These findings suggest that when given longer letters, GPs read them and, while they may complain about the length, they are unable to identify what to cut. If offered shorter letters with the option of obtaining more information, the offer is declined. There is room to differentiate between the information required at first contact and that required for repeat admissions. All surveys reveal a wide range of opinions.
Some studies have looked at the content that GPs want.
8,9,13–15 While it is evident that GPs can express priorities15 or identify a “top ten, “9 there is no agreement on what is redundant. Dunn and Burton13 conducted the clearest study on this: 15 GPs rated 18 items, and only one GP rated any item as ‘irrelevant’; all other items were rated as at least ‘helpful at times’ by all GPs. The same study discovered that GPs did not recognize what could be usefully withheld from letters.
The only consistent viewpoint is that some items frequently considered necessary by GPs, particularly management plans after discharge, are rarely recorded by psychiatrists.
7,9,13,16, and what information has been provided to the patient and caregivers.
7,9,11,13 Butler and Greenberg3 reported that only 4-19% of day hospital patients were informed of their diagnosis by the time they were discharged, so silence on this last point may be appropriate.
As a result, there currently needs to be a clear consensus on establishing a standard against which an audit can be performed. Even though the current study was conceived in an audit context and approved by audit mechanisms, it is a pre-audit survey to establish a standard, not part of a current audit cycle.
We created a questionnaire to assess the importance GPs place on the information reported in a discharge summary. We included the standard discharge summary sections as well as the information identified by Dunn and Burton as critical. 13 We did not include information that was reported as standard in the heading of a discharge summary but was deemed essential (e.g., identifying information, consultant’s name, dates of admission and discharge, Mental Health Act status, and CPA level). GPs were asked to state their attitude to the inclusion of a specific item in the discharge summary using the ratings ‘information I do not want in a discharge summary,’ ‘information I feel neutral about,’ ‘information I would like in a discharge summary’ and ‘information I consider essential in a discharge summary.’ The information in discharge summaries for first and subsequent admissions were rated separately. In the questionnaire’s final section, GPs were asked for additional comments and recommendations on how to discharge summaries could be improved.
Four community mental health teams provided secondary adult mental health services in Peterborough at the time of the survey. These teams maintained up-to-date lists of GP practices and GPs in their area, and we drew the GPs for this survey. If a surname appeared more than once or in more than one practice, the practice was contacted to determine whether it was the same or two different practitioners. GPs who work in multiple practices received only one questionnaire. A total of 122 questionnaires were distributed to 39 different practices. The questionnaires were anonymous and came with an addressed prepaid return envelope and an explanation of the questionnaire. To increase the return rate, questionnaires were designed to fit on a single page, be quick to complete, and be simple to understand.
Because the study began as a pre-audit standard-setting exercise, it was approved by the clinical audit and clinical effectiveness teams following the Trust’s clinical governance procedures and national guidance.Tooltip Text
psychiatric discharge summary note. See attached instructions