Readability of patient discharge instructions with and without the use of electronically available disease-specific templates

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This is the first review of the article "Readability of patient discharge instructions with and without the use of electronically available disease-specific templates".[1]

Background and Significance

At the time of discharge, patients may be preoccupied with the thoughts of coping after the hospitalization and may not recall verbal instructions given to them by their providers. Typically in US hospitals, discharge instructions are given in the written format. Due to low health literacy, many US adults may not understand these written discharge instructions. In this article authors have retrospectively reviewed the discharge instructions given to the patients for their readability through the use of templates in Electronic Health Records (EHRs).

Materials and Methods

A retrospective, cohort analysis technique was used in this study. The study was conducted at Brigham and Women’s Hospital (BWH), a large tertiary care center in Boston, Massachusetts. The subjects were randomly chosen from a population that comprised of adults that were 18 and older and who were discharged home and received discharge instructions.

BWH implemented a web based “discharge module” in 2011.[1] For this module, discharge instruction templates, templates that were diagnoses specific after the discharge and developed by obtaining the feedback from the appropriate specialties, were created. At the time of discharge, physicians had options to write their own discharge instructions even if a specific template was available, use the discharge instruction templates as such, or modify these templates. If no template existed for the patient diagnosis, physicians wrote their own discharge instructions.

245 random subjects were chosen for this study. Out of this sample 233 were eligible. Data were analyzed for readability by using the Microsoft Office word 2007 for Flesch Reading Ease Level (FREL) scale and the Flesch-Kincaid Grade Level (FKGL) scale.

The subjects were divided into two groups; one group consisted of patients who received clinician initiated discharge instructions. This group was divided into two subgroups, diagnosis specific discharge instruction template was available but not used and no diagnosis specific template was available. The other group consisted of subjects who received pre-developed diagnosis specific discharge instructions with or without modifications.


Data analysis revealed that the pre-developed templates scored better in readability analysis. This pattern persisted even when the subjects, for which no diagnosis specific discharge template was available, were removed from the final analysis. It was done to remove a potential bias that the lack of diagnosis specific template may mean that these patients had complex illness requiring complex discharge instructions.


In this study, authors found that pre-developed diagnosis specific discharge instructions even if modified resulted in better readability. This effect persisted even when after removing the subgroup from analysis for whom no diagnosis specific discharge template was available.

My comments

This study shows that it is possible to develop diagnosis specific discharge instructions that can be customized to meet the needs of a specific patient and still score better on readability as compared to the discharge instructions generated on the fly. However, it required a group of clinicians with the help of subject experts to develop such templates. It is not clear from this study whether this resulted in better outcomes. However, it makes sense to provide written helpful discharge instructions that can be easily understood by patients with inadequate literacy. In another article Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications the authors identified that up to 40% of discharge instructions have one or more medication discrepancy due to inaccurate discharge instructions, despite using EHR for these instructions. This highlights the importance of developing better communications between the hospitalists and primary care providers. An electronically created discharge summary Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries may be useful here.

Related Articles


  1. 1.0 1.1 Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005