Electronic discharge summaries--are they being done and do they have the required information?
A retrospective audit was conducted to evaluate the completeness of the available electronic discharge summaries. Forty-five randomly selected patients had their respective electronic discharge summaries reviewed including criteria such as length of stay; discharge summary availability; documentation of discharge medications; medication changes; medical co-morbidities and follow-up arrangements. There were electronic discharge summaries available for thirty-six (80%) of the included patients of which; thirty-three (91.7%) had the medication list available; twenty-six (72.2%) had clear documentation of medication changes; thirty-five (97.2%) had clear documentation of the patients' co-morbidities; and thirty (83.3%) had clear follow-up plans documented. The readmission rate was found to be high when compared to published numbers with a quarter of the discharged patients being readmitted within 28 days. The recommendations resulting from this audit include the need for improved education on the requirements of the electronic dischange summary, appropriate documentation and possible implementation of out-of-hour discharge summary availability.
J P
JP
Mamo
D000293:Adolescent; D000369:Aged, 80 and over; D003266:Continuity of Patient Care / Q000458:organization & administration; D004282:Documentation / Q000379:methods / Q000592:standards*; D005260:Female; D055991:Health Records, Personal; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D007494:Ireland; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010351:Patient Discharge / Q000592:standards*; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies