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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