Strengthening Information Capture in Rehabilitation Discharge Summaries: An Application of the Siebens Domain Management Model

• Published in: PM & R 2013-03, Vol.5 (3), p.182-188
• Main Authors: Kim, Woojae, MD, Charchian, Beny, MD, MS, Chang, Eric Y., MD, Liang, Li-Jung, PhD, Dumas, Armen J., MD, Perez, Mario, MD, Siebens, Hilary C., MD, Kim, Hyung S., MD
• Format: Article
• Language: English
• Subjects: Case Management; Documentation; Female; Humans; Male; Patient Discharge; Physical Medicine and Rehabilitation; Rehabilitation
• ISSN: 1934-1482; 1934-1563
• DOI: 10.1016/j.pmrj.2013.01.003

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 (© 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.