AUDIT ON DISCHARGE SUMMARIES

DR NIRANJAN PDR K LAKSHMANDR M S SRIDHARAUDIT ON DISCHARGE SUMMARIESPrimary documents communicating a patients care plan to the post-hospital care teamOften, the discharge summary is the only form of communication that accompanies the patient to the next setting of care.High-quality discharge summaries are essential for promoting patient safety during transitions between care settingsKind AJH, Advances in Patient Safety, 2008The Joint Commission has established standards outlining the components that each hospital discharge summary should containComponents are:1.Reason for hospitalization.2.Significant findings.3.Procedures and treatment provided.4.Patients discharge condition.5.Patient and family instructions (as appropriate).6.Attending physicians signature.

Kind AJH, Advances in Patient Safety, 2008No clear and specific definition exists in the published literature for these components.Additionally, it is not clear to what extent these standards are met in hospital discharge summariesThe present audit was carried out to compare the status and standard of our discharge summaries when compared to Joint commission standards Kind AJH, Advances in Patient Safety, 2008Audit was carried out after designing a protocol and then analyzing our discharge summaries from the month of January to June 2013

Total number of discharge summaries audited -374

REASON FOR HOSPITALIZATION

YESNOERRORSType of ErrorsChief complaints86.7%13.3%26.7%Short forms, AbsentHistory of the presenting complaints100%066.7%Spelling mistakes, Short forms, IncompletePast History/Co morbidities73.3%26.7%66.7%Spelling mistakes, Short forms, Incomplete, Absent

SIGNIFICANT FINDINGSYesNo ErrorsTypePrimary Diagnosis100%00Secondary Diagnosis100%020%Short forms , MissingPROCEDURES AND TREATMENT PROVIDEDYesNoErrorsTypeHospital Course100%053.3%Spelling mistakes, Short forms, Incomplete, Missing words

Hospital Consults100%020%Secondary consultant missingHospital Procedures93.3%6.7%13.3%Short forms , AbsentSummary of relevant investigations6.7%93.3%93.3%AbsentOPERATIVE NOTESYesNoErrorsTypeSurgeon Details93.3%6.7%6.7%AbsentAnaesthetist Details93.3%6.7%13.3%Absent , IncorrectProcedure Performed93.3%6.7%13.3%Absent, Short formsType of anaesthesia93.3%6.7%100%Short forms, AbsentFindings86.7%13.3%20%Short forms, AbsentProcedure Details93.3%6.7%33.3%Short forms, Absent, Spelling mistakePATIENTS DISCHARGE CONDITIONYesNoErrorsTypePatient's health status on discharge93.3%6.7%6.7%AbsentPATIENT/FAMILY INSTRUCTIONS (AS APPROPRIATE)YesNoErrorsTypeDischarge medications100%073.3%Incomplete, Short forms, Spelling mistakesActivity/Therapy orders13.3%86.7%86.7%AbsentDietary instructions26.7%73.3%73.3%AbsentPlans for medical follow up100%06.7%IncompleteATTENDING PHYSICIANS SIGNATURE

YesNoErrorsTypeSignature of the Consultant100%00Signature of the Resident86.7%13.3%60%No Name EMERGENCY CONTACT NUMBERSYesNoErrorsTypeContact Number100%00DISCUSSIONDischarge summaries included all 6 of the joint commission recommended componentsMajority of the errors may not be significant clinicallyErrors in discharge medications could lead to potential clinical as well as medicolegal implicationsMajority of them can be overcome by inclusion of templatesMost (88-100 percent) discharge summaries included five of the six Joint Commission components. The remaining component, patients discharge condition, was included the least often (79-90 percent)Kind AJH, Advances in Patient Safety, 2008RECOMMENDATIONTo include templates onActivityConsultsTherapyDischarge MedicationsNames of the ResidentsTo educate the residents Including the template for Referral doctor may be helpful for post discharge care deliveryCONCLUSIONOverall, discharge summaries adhere well to Joint Commission discharge summary component standards.

Even a small frequency of errors in information provided is a concern and may affect patient safety.THANK YOU