Key result
PDQI-9 SV assessment provides no clinical results because the provided text lacks actual study content.
Why the study?
Incomplete discharge summaries can lead to adverse events and readmissions, but the quality of electronic discharge summaries had never been systematically evaluated at this hospital.
Cross-Sectional
The quality of electronic discharge summaries in an internal medicine service was generally good, though conciseness was identified as an area for targeted educational improvement.
Targeted education should address discharge summary conciseness; extends observational data showing no variation by seniority or weekday.
Background Hospital discharge represents a critical moment in the inpatient care process, and its documentation, known as the discharge summary, plays a fundamental role. Incomplete discharge summaries may lead to hospital readmissions, adverse events, poor understanding of treatment and disease, patient and family dissatisfaction, lack of follow-up, and discontinuity of care. In 2017, Hospital Municipal de Agudos “Dr. Leónidas Lucero” (Bahía Blanca, Buenos Aires Province, Argentina) implemented an electronic health record (EHR) system. Although substantial experience has been gained in its use, the quality of discharge summaries has never been systematically evaluated. Objective To assess the quality of discharge summaries produced between July 2023 and June 2024 by the Internal Medicine Inpatient Service using the Physician Documentation Quality Instrument–9 Spanish Version (PDQI-9 SV). Methods An observational, descriptive, cross-sectional study was conducted. The PDQI-9 SV consists of nine items (up-to-date, accurate, thorough, useful, organized, comprehensible, concise, synthesized, and internally consistent), each scored on a 5-point Likert scale. Prior to data collection, an instrument adaptation process and reviewer training were carried out.The assessment was done by two trained physician reviewers. Results A total of 135 discharge summaries were analyzed. The mean overall quality score was 34.77 (SD = 4.17). The highest-scoring domains were accuracy (mean = 4.32; SD = 0.43), completeness (mean = 4.02; SD = 0.85), and internal consistency (mean = 4.01; SD = 0.65). The lowest-scoring domain was conciseness (mean = 3.28; SD = 0.90). No statistically significant differences were observed according to physician seniority (p = 0.757) or day of the week (p = 0.809). Inter-rater agreement was moderate (ICC = 0.63; 95% CI: 0.45–0.75). Conclusions Overall discharge summary quality was good, with strengths in accuracy, completeness, and internal consistency. The absence of differences according to physician seniority or day of completion suggests homogeneous documentation practices. Lower scores in conciseness highlight a clear opportunity for targeted educational interventions.
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Carral et al. (2026) conducted a cross-sectional in Quality of Electronic Discharge Summaries. PDQI-9 (Spanish Version) was evaluated.
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