Article

OBJECTIVE: To increase relevant information capture in inpatient rehabilitation
discharge summaries. DESIGN: In July 2008, the Siebens Domain Management Model
(SDMM) was incorporated into discharge summaries. This model organizes patients'
health-related issues into 4 domains: I. Medical/Surgical Issues, II. Mental
Status/Emotions/Coping, III. Physical Function, and IV. Living Environment ((c)
Hilary C. Siebens MD 2005). Discharge summary content was measured through
retrospective chart review. SETTING: An inpatient rehabilitation unit affiliated
with a physical medicine and rehabilitation residency program. PARTICIPANTS:
Forty cases with discharge summaries: 20 traditional reports (historic controls)
and 20 SDMM reports after model introduction randomly chosen from residents'
final inpatient rotation week. METHODS: A documentation review form included 36
items that covered the 4 SDMM domains and assessed item presence in reports. The
Global score and 4 Domain scores per each patient report were calculated to
reflect the percentage of items present in the entire report and each domain,
respectively. Descriptive statistics for these scores were generated and compared
between traditional and SDMM reports by using a 2-group t-test. MAIN OUTCOME
MEASUREMENTS: Global scores and Domain scores. RESULTS: Global scores increased
from 34% to 53% of items present in traditional versus SDMM reports respectively
(P < .001); Domain Scores also increased in domains I (81% to 92%, P = .047), II
(9% to 47%, P < .001), III (25% to 34%, P = .062), and IV (11% to 33%, P < .001).
CONCLUSION: Traditional rehabilitation discharge summaries lacked information
relevant to rehabilitation care. Information capture and total relevant report
content increased significantly after SDMM integration into reports.
CI - Copyright (c) 2013 American Academy of Physical Medicine and Rehabilitation.
Published by Elsevier Inc. All rights reserved.

Langue : ANGLAIS