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Discharge Summaries Often Lack Pending Test Results

Last Updated: August 13, 2009.

Hospital discharge summaries often do not contain information on pending test results or provider follow-up information, which can lead to medical errors, according to a study in the September issue of the Journal of General Internal Medicine.

THURSDAY, Aug. 13 (HealthDay News) -- Hospital discharge summaries often do not contain information on pending test results or provider follow-up information, which can lead to medical errors, according to a study in the September issue of the Journal of General Internal Medicine.

Martin C. Were, M.D., and colleagues from Indiana University School of Medicine in Indianapolis reviewed the hospital discharge summaries from 668 patients identified as having pending test results from electronic medical records to determine whether information about pending tests and follow-up providers was mentioned.

The researchers found that only 16 percent of 2,927 tests with pending results were mentioned in discharge summaries. Only 25 percent of discharge summaries mentioned any pending tests. The documentation rate was not affected by a number of factors, including the experience of the provider preparing the summary, length of hospitalization, patient age or race, or length of time for results to return. In addition, the authors note, only 67 percent of summaries contained information on the follow-up provider.

"Discharge summaries are grossly inadequate at documenting both tests with pending results and the appropriate follow-up providers," Were and colleagues conclude. "Strategies to close this quality gap are needed so as to reduce errors related to missed test results."

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