The surgical discharge summary: a lack of substantial clinical informationmay affect the postop treatment of rectal cancer patients

Background and aims: The discharge summary is crucial for patient aftercare as it is the main document for communicating information on patient data b etween the hospital and the primary care practitioner. The aim of this stud y was to assess the completeness of hospital discharge summaries and to det ermine whether the inclusion or omission of specific items of clinical info rmation may affect further patient care. Patients/methods: A population bas ed cohort study including patients with rectal cancer from April 1996 throu gh March 1998 in the Munich region. Five hundred and thirty-seven discharge summaries were evaluated for completeness of clinical-and tumor-related in formation. In addition, the association between recommendation for (dischar ge summary)and initiation of adjuvant therapy after discharge was evaluated . Results: Information about T and N category was given in 98%, about metas tasis in 90%, and about residual tumor in 73% of all discharge summaries. F ollow-up was recommended in only 68% of the summaries. No adjuvant therapy was administered to 5/5 patients with N+, T1/2 tumors nor to 14/17 patients with N+, T3/4 tumors if correspondent recommendations were missing. Conclu sion: Lack of crucial information in surgical discharge summaries is not on ly surprisingly common, but may also negatively affect patient aftercare.