Evaluation of computer generated neonatal discharge summaries.
Computer generated and dictated discharge summaries were compared for all 133 babies admitted for intensive and special care during a six month period. Whereas 130/133 (98%) had a computer generated summary, only 94/133 (71%) had a dictated summary. In addition, computerised summaries were completed at discharge, but there was a delay up to 26 weeks for dictated summaries. Dictated summaries had more items of basic data missing but were more readable. A main diagnosis was missing in only 5/95 (5%) of dictated and 1/130 (1%) computerised summaries. Of the computer generated summaries, 114/133 (86%) were suitable to give to parents. Satisfactory discharge summaries for babies requiring intensive or special care can be generated with an on line computer system.
Lissauer
T
T
Paddington Green Children's Unit, St Mary's Hospital, London.
Paterson
C M
CM
Simons
A
A
Beard
R W
RW
D003142:Communication; D004739:England; D006801:Humans; D007231:Infant, Newborn; D015931:Intensive Care, Neonatal / Q000458:organization & administration*; D016347:Medical Records Systems, Computerized; D008838:Microcomputers; D010290:Parents; D010351:Patient Discharge; D013997:Time Factors