1. Buterakos, Roxanne DNP, RN, PNP-BC, AG-ACNP-BC
  2. Cooper, Denise DNP, RN, ANP-BC

Article Content

Skilled nursing facility (SNF) residents diagnosed with urinary tract infections (UTIs) often return from the hospital with insufficient information to confirm the diagnosis and treatment they received at the hospital. This lack of documentation can affect residents' outcomes and quality of care when they return to the SNF. Negative outcomes can include care replication, missed diagnoses for conditions that require additional treatment, inappropriate antibiotic use, increased drug resistance, superinfections (eg, Clostridium difficile infection) from overuse of antibiotics, overlooked medication changes, staff time spent making inquiries about care and follow-up, missed specialist follow-up appointments, and breaks in care continuity.


In 2009, the American Recovery and Reinvestment Act (ARRA) mandated that all medical documentation transition to electronic medical records (EMRs) by 2014 or face Medicare reimbursement reductions in 2015.1,2 Prior to the widespread use of EMRs, some hospitals provided SNFs a full chart copy containing all patient data. This practice allowed SNFs to access hospital documentation of diagnoses, prescriptions, and follow-up recommendations to plan and manage resident care. With the advent of ARRA and EMR, the use of full chart copies has become obsolete. Consequently, the documentation hospitals share with SNFs varies widely. Further complicating matters, most SNFs and hospitals use different EMR formats, making seamless electronic information sharing nearly impossible.



This secondary study stemmed from initial research examining UTI diagnosis and treatment of SNF residents who were hospitalized and discharged back to the SNF. While reviewing these charts, we noted a deficiency in discharge documentation hospitals provided to the SNFs. Therefore, the objective of this study was to identify the amount and type of patient records that hospitals provided to SNFs.



A retrospective analysis of the medical records of hospitalized SNF residents who were transferred back to the SNF was conducted over 3 years. The university's institutional review board designated the study exempt (HUM00166265).


Sample and setting

The SNF residents included in this secondary study had been transferred to one of 4 hospitals (for any reason) from 3 southeast Michigan SNFs. These facilities, with a 427-bed capacity, provide care for both long-term care and rehabilitation residents and are owned and managed by the same corporation.


Procedures and measures

Data were accessed and abstracted from the SNF EMR of residents who had been hospitalized during a 3-year period (2017-2020). For the initial study, hospital documents of eligible residents were reviewed to determine the appropriateness of UTI diagnoses. For the current study, all discharge documents on these 79 residents the hospitals shared with the SNFs were reviewed including hospital discharge summaries, laboratory test results, medications, admission history and physical examination, testing/radiology results, consults, and other medical documents (eg, social work, provider, and nursing notes). Using descriptive statistics, each variable was analyzed by calculating percentages.



Over the 3-year period, 621 residents transitioned back to SNFs after hospitalization. Of those, 79 had a documented UTI diagnosis and treatment from the hospital. Of these charts with only a UTI diagnosis, 94.9% included discharge summaries, 82.3% included medication lists, 54.4% included admission history and physical examinations, 31.6% included testing/radiology results, 21.5% included consults, 15.2% included other documentation (eg, primarily medical social work notes), and only 11.4% included laboratory test results.



Analysis indicated that communication and documentation transfer between facilities varied widely. Because nurses and providers often do not communicate when residents are transferred back to the SNF, transfer documents are the primary source of information used to understand the residents' treatment during hospitalization and the anticipated care plan at the SNF. Poor communication in transitional care impedes resident care and may affect resident outcomes.


In most cases, the discharge summaries lacked sufficient medical decision-making information (eg, admitting history and physical examinations, laboratory test results, radiology reports, consult notes, and medications) to guide SNF clinicians in providing transitional care for its returning residents. Furthermore, documents the hospitals shared with the SNFs varied by facility, over time, and from resident to resident. While documentation of posthospitalized care is critical to residents' outcomes, such documentation is often unavailable or difficult to access.3 After surveying providers about transitional care provided to residents returning to the SNF after hospitalization, Britton and colleagues4 found mismatched transfer and discharge forms, missing medication lists, a lack of patient hospital history, and missing treatment plans.


While we found that the shared documents were missing UTI diagnosis information, it can be reasonably presumed that this phenomenon is not exclusive to UTIs, likely extending to other diagnoses. Moreover, although these study findings were incidental, they revealed a problem that may be affecting transitional care and patient outcomes, possibly on a more widespread basis. One suggestion for further study is to create and test a discharge process in which an encrypted portal access, similar to a patient portal, is given to SNFs by hospitals to provide SNF readmission coordinators immediate access to specified inpatient documents. This encrypted access could help bypass EMR communication issues experienced between SNFs and hospitals. Furthermore, this process could help ensure SNFs have access to all requested documentation, eliminating the need for the current practice of hospitals printing and sending paper charts to the SNFs to be scanned and uploaded into patient EMRs. Finally, SNF providers could be given off-site access to readmission documents to improve care transition.



The results of this study highlight the need for more effective communication and documentation between hospitals and SNFs, as well as a consistent transitional care process between the 2 facilities. Establishing a process whereby hospitals consistently share complete documentation with SNFs could provide a complete picture of the hospital care residents received and help improve resident care outcomes. Such initiatives also have the potential to reduce care duplication (eg, follow-up phone calls to hospitals and specialists), prevent missed diagnoses that require follow-up, identify medication changes, and reduce inappropriate antibiotic treatments.




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