Meaningful Use Norm - Provider Discharge Communications

What is it?

An appropriate discharge document must be filed for all admitted patients when leaving a facility without expectation of return. Patients may leave by virtue of being discharged home, transferred to another facility, dying or leaving against medical advice. When adding a final encounter summation note to a patient's chart, "Discharge Summary" is the correct note type and within this type, templates for "Discharge Summary", "Deceased Note" and "Transfer Note" are appropriate.  

Completion of timely and appropriately structured summative documentation for all inpatient encounters is among the Connect Care Meaningful Use Norms, with compliance feedback provided through Meaningful Use Norms Dashboards.

Why does it matter?

Discharge documentation summarizes what happens during an inpatient encounter. It also serves as a care coordination tool, communicating to other providers in the patient's circle of care to facilitate a shared understanding of remaining active problems, intended home medications and post-discharge expectations, accountabilities and follow-up arrangements. 

Confirming the attachment relationship between a primary care provider and a patient is a crucial step in ensuring that discharge communications are received as part of a bidirectional flow of information between primary care providers and hospitals. Confirmation needs to occur as early as possible in the admission process. 

Who is responsible?

The discharging attending prescriber is responsible for ensuring that discharge documentation is completed and signed. As the responsible provider, documents drafted by others (e.g., medical students) or signed by trainees (e.g., residents with cosign requirement) should be reviewed and edited to ensure that provincial standards for structure and content are adhered to.

How is it done?

Alberta's "consumers" (primary care providers, community specialty providers and care team providers) have repeatedly identified improved communication across transitions of care as a top priority for healthcare improvement. Specific content desiderata include:


Standardized Format and Structure

Standardized Content

Transition Care Plan

Particular attention should be given to a transition care plan bridging inpatient with outpatient care. It may be reflected in hospital problem assessments and plans, as well as medication reconciliation,  "Follow Up Arrangements" and "Community Supports" sections. Many hospital encounters are straightforward and call for simple transition plans which may be limited to an indication of who will follow up unresulted investigations, who will take care of prescription refills and by when a primary care or community provider should be seen. More complex transition plans add information about coordination of primary care, speciality and community service accountabilities.

Standardized Templates

Provincially standardized templates, with approved specialty variants, have been developed and deployed within Connect Care to support encounter summaries specific to discharged, deceased and transferred (inter-facility) contexts. These address summary consumer needs while fulfilling accreditation, facility and professional standards.

How is compliance promoted?

Feedback about adherence to discharge documentation content meaningful use norms is provided to through a "Connect Care Meaningful Use Norms Feedback" display available in the Hyperspace "Dashboards" activity for all inpatient providers. 

Evaluating the quality content of discharge documentation is currently limited to detecting the presence of structured data elements expected within expected summary sections. In addition, note properties (e.g., length, use of copy-paste, structured vs free-text vs dictated content, etc.) of the note. Qualitative analysis of documentation text may be done from time to time as part of quality assurance activities or audits by professional licensing organizations.

Discharge documentation that addresses key content requirements (e.g., a clear transition of care plan), may be reflected by use of standardized building blocks that more commonly appear in compliant documents. Metrics are identified and deployed to help users more rapidly identify opportunities for improvement. Examples include:

Derivation of these metrics is explained further in the Connect Care Builder Handbook, with links to data quality definitions.