Assessing Documentation of Critical Imaging Result Follow-up Recommendations in Emergency Department Discharge Instructions

J Digit Imaging. 2018 Aug;31(4):562-567. doi: 10.1007/s10278-017-0039-6.

Abstract

To facilitate follow-up of critical test results across transitions in patient care settings, we implemented an electronic discharge module that enabled care providers to include follow-up recommendations in the discharge instructions. We assessed the impact of this module on documentation of follow-up recommendations for critical imaging findings in Emergency Department (ED) discharge instructions. We studied 240 patients with critical imaging findings discharged from the ED before (n = 80) and after (n = 160) implementation of the module. We manually reviewed hand-written forms and electronic discharge instructions to determine if follow-up recommendations were documented. Follow-up recommendations in ED discharge instructions increased from 60.0% (48/80) to 73.8% (118/160) post-module implementation (p = 0.03), a relative increase of 23%. There was no significant change in the rate of documented critical imaging findings in the discharge instructions (77.5% [62/80] before the intervention and 76.9% [123/160] after the intervention; p = 0.91). Implementation of a discharge module was associated with increased documentation of critical imaging finding follow-up recommendations in ED discharge instructions. However, one in four patients still did not receive adequate follow-up recommendations, suggesting further opportunities for performance improvement exist.

Keywords: Care continuity; Care transitions, health; Discharge summaries, patient; Emergency care information systems; Radiology information system.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Academic Medical Centers
  • Adult
  • Critical Care / methods
  • Diagnostic Imaging / methods*
  • Diagnostic Imaging / statistics & numerical data
  • Documentation
  • Electronic Data Processing / organization & administration*
  • Electronic Health Records / organization & administration*
  • Emergency Service, Hospital
  • Female
  • Humans
  • Magnetic Resonance Imaging / methods
  • Male
  • Patient Discharge*
  • Program Evaluation
  • Quality Improvement*
  • Radiography, Thoracic / methods
  • Radiology Information Systems
  • Tomography, X-Ray Computed / methods
  • United States