ArticleJournal of evaluation in clinical practice2021
Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria.
Article in Journal of evaluation in clinical practice, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 15 papers.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
15 citing papers in PubMed.
- Patient-centered discharge summaries to support safety and individual health literacy: a double-blind randomized controlled trial in Austria.BMC health services research · 2024Trial
- End-to-end pipeline for automated heart failure diagnosis with clinical notes using SNOMED-CT.Scientific reports · 2026Article
- Quality of integrated care for patients with multimorbidity in China: a Servqual Model analysis.BMC health services research · 2026Article
- Audit and Re-Audit of Discharge Summaries Completeness: A Strategy to Improve Patient Care Quality.Pakistan journal of medical sciences · 2025Article
- Diagnosis Documentation Done Right: Cross-Specialty Standard for the Diagnosis Section in German Discharge Summaries - A Mixed-Methods Study.Journal of general internal medicine · 2025Article
- Auto-expansion software prompting reduces abbreviation use in electronic hospital discharge letters: an observational pre- and post-intervention study.BMC medical informatics and decision making · 2025Observational
- Processing of Short-Form Content in Clinical Narratives: Systematic Scoping Review.Journal of medical Internet research · 2024Article
- Disambiguation of acronyms in clinical narratives with large language models.Journal of the American Medical Informatics Association : JAMIA · 2024Article
- Article
- Completeness of medication information in admission notes from emergency departments.BMC health services research · 2023Article
- Deciphering clinical abbreviations with a privacy protecting machine learning system.Nature communications · 2022Article
- A retrospective analysis of discharge summaries from a tertiary care hospital medical oncology unit: To assess compliance with documentation of recommended discharge summary components.Cancer reports (Hoboken, N.J.) · 2022Article
- Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria.Journal of evaluation in clinical practice · 2021Article
- Design and preliminary evaluation of a newly designed patient-friendly discharge letter - a randomized, controlled participant-blind trial.BMC health services research · 2021Article
- Unsupervised SapBERT-based bi-encoders for medical concept annotation of clinical narratives with SNOMED CT.Digital healthArticle
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
8 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
RATIONALE AND
objectiveThe discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations.
methodOne hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4-point Likert-type scale ranging from "strongly agree" to "strongly disagree" (or "not relevant"). Subsequently, the results were discussed among reviewers to achieve a consensus decision.
resultsThe mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS.
conclusionsIn conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.