Laupacis, Andreas,van Walraven, Carl G.2009-03-232009-03-2319981998Source: Masters Abstracts International, Volume: 36-06, page: 1581.9780612284678http://hdl.handle.net/10393/8634http://dx.doi.org/10.20381/ruor-15916Background. The discharge summary is an important method of communicating information necessary for continuing patient care. Deficiencies in discharge summary content, accuracy, and timeliness are a common problem. To improve summaries, studies have assessed physician-in-training (housestaff) education, alteration of the summary format; and collating information within computer databases into a summary. The most promising technology for improving discharge summaries is the clinical database. Primary objective. To compare medical discharge summaries generated from a clinical database with those created by narrative letter dictation. Design. Randomized controlled trial assigning patients to database (DB) or dictated (dictated-random or D-R) summaries. This was preceded by a prospective cohort study where summaries for all patients were created by dictation (dictated-cohort or D-C group). Inclusion criteria and study setting. All patients admitted to and discharged alive from the general internal medicine service in a tertiary care teaching hospital. Intervention. For patients randomized to the DB group, housestaff completed forms capturing hospital and discharge information important for the discharge summary. This information was entered into a database along with portions of the admission history and physical-examination form. Information in the database was collated into a report to create a database discharge summary. For patients in the D-R and the D-C group, housestaff used narrative dictation to create summaries. (Abstract shortened by UMI.)142 p.Health Sciences, Medicine and Surgery.Thesis