JMIR Publications

ABSTRACT

Background:

Discharge summaries (DS) are key clinical documents at the interface between inpatient and outpatient care. Their quality affects continuity of care, coordination, and patient safety, yet information transfer at discharge is often incomplete, delayed, or unclear. Standardized instruments for assessing DS quality remain scarce.

Objective:

To develop a structured, recipient-oriented quality assessment instrument (QAI) for physician discharge summaries (DS) as a pragmatic measure of discharge communication quality and to conduct an initial evaluation of its applicability and interrater reliability.

Methods:

We conducted a formative instrument-development study using a Delphi-based author-panel consensus process, condensing 43 recipient-oriented DS criteria into 12 items across three domains: medical content, structure and organization, and language and clarity. It was applied in a pragmatic pilot reliability evaluation to 20 anonymized internal medicine DS, independently assessed by five physician raters with heterogeneous clinical backgrounds who were not involved in QAI development. Interrater reliability was evaluated using Krippendorff's alpha and quadratically weighted Gwet's AC2. Reporting followed the Guidelines for Reporting Reliability and Agreement Studies.

Results:

The median overall quality score was 78.5% (IQR 75.3%-82.5%), and the mean was 79.1% (SD 5.0%). Scores were highest for language and clarity and lowest for medical content. Interrater reliability was 0.76 for AC2 and 0.45 for alpha.

Conclusions:

The QAI provides preliminary evidence for a clinically applicable approach to assessing key quality dimensions of physician DS. It showed good interrater agreement, with domain-specific variation, particularly for language and clarity. These findings support its use for exploratory quality improvement, audit and feedback, educational purposes, and future evaluation of digitally supported discharge documentation, while highlighting the need to balance linguistic quality with clinically actionable content.