Transcript AUDIT ON DISCHARGE SUMMARIES

AUDIT ON DISCHARGE SUMMARIES
DR NIRANJAN P
DR K LAKSHMAN
DR M S SRIDHAR
 Primary documents communicating a patient’s care plan to
the post-hospital care team
 Often, 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
settings
Kind AJH, Advances in Patient Safety, 2008
 The Joint Commission has established standards outlining the
components that each hospital discharge summary should
contain
 Components are:
 1.Reason for hospitalization.
 2.Significant findings.
 3.Procedures and treatment provided.
 4.Patient’s discharge condition.
 5.Patient and family instructions (as appropriate).
 6.Attending physician’s signature.
Kind AJH, Advances in Patient Safety, 2008
 No 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 summaries
 The 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, 2008
 Audit 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
YES
NO
ERRORS
Type of Errors
Chief complaints
86.7%
13.3%
26.7%
Short forms, Absent
History of the
presenting
complaints
100%
0
66.7%
Spelling mistakes, Short forms,
Incomplete
Past History/
Co morbidities
73.3%
26.7%
66.7%
Spelling mistakes, Short forms,
Incomplete, Absent
SIGNIFICANT FINDINGS
Yes
Primary
Diagnosis
Secondary
Diagnosis
No
Errors Type
100% 0
0
100% 0
20%
Short forms , Missing
PROCEDURES AND TREATMENT
PROVIDED
Yes
No
Errors Type
100%
0
53.3%
Spelling mistakes, Short forms,
Incomplete, Missing words
Hospital
100%
Consults
Hospital
93.3%
Procedures
Summary of 6.7%
relevant
investigations
0
20%
Secondary consultant missing
6.7%
13.3%
Short forms , Absent
93.3
%
93.3%
Absent
Hospital
Course
OPERATIVE NOTES
Yes
No
Errors Type
Surgeon
93.3%
Details
Anaesthetist 93.3%
Details
6.7%
6.7%
Absent
6.7%
13.3%
Absent , Incorrect
Procedure
Performed
93.3%
6.7%
13.3%
Absent, Short forms
Type of
anaesthesia
93.3%
6.7%
100%
Short forms, Absent
Findings
86.7%
13.3
%
20%
Short forms, Absent
Procedure
Details
93.3%
6.7%
33.3%
Short forms, Absent, Spelling mistake
PATIENT’S DISCHARGE CONDITION
Patient's health
status on
discharge
Yes
No
Errors
Type
93.3%
6.7%
6.7%
Absent
PATIENT/FAMILY INSTRUCTIONS (AS
APPROPRIATE)
Yes
No
Errors
Type
Discharge
medications
100%
0
73.3%
Incomplete,
Short forms,
Spelling
mistakes
Activity/
Therapy
orders
13.3%
86.7%
86.7%
Absent
Dietary
instructions
26.7%
73.3%
73.3%
Absent
0
6.7%
Incomplete
Plans for
100%
medical follow
up
ATTENDING PHYSICIAN’S SIGNATURE
Yes
No
Errors
Signature of the
Consultant
100%
0
0
Signature of the
Resident
86.7%
13.3%
60%
Type
No Name
EMERGENCY CONTACT NUMBERS
Contact
Number
Yes
No
Errors
100%
0
0
Type
DISCUSSION
 Discharge summaries included all 6 of the joint commission
recommended components
 Majority of the errors may not be significant clinically
 Errors in discharge medications could lead to potential
clinical as well as medicolegal implications
 Majority of them can be overcome by inclusion of templates
 Most (88-100 percent) discharge summaries included five of
the six Joint Commission components.
 The remaining component, “patient’s discharge condition,”
was included the least often (79-90 percent)
Kind AJH, Advances in Patient Safety, 2008
RECOMMENDATION
 To include templates on
 Activity
 Consults
 Therapy
 Discharge Medications
 Names of the Residents
 To educate the residents
 Including the template for Referral doctor may be helpful for
post discharge care delivery
CONCLUSION
 Overall, 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