DR NIRANJAN P DR K LAKSHMAN DR M S SRIDHAR AUDIT ON DISCHARGE SUMMARIES

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 YESNOERRORSType of Errors Chief complaints86.7%13.3%26.7%Short forms, Absent History of the presenting complaints 100%066.7%Spelling mistakes, Short forms, Incomplete Past History/ Co morbidities 73.3%26.7%66.7%Spelling mistakes, Short forms, Incomplete, Absent

SIGNIFICANT FINDINGS YesNoErrorsType Primary Diagnosis 100%00 Secondary Diagnosis 100%020%Short forms, Missing

PROCEDURES AND TREATMENT PROVIDED YesNoErrorsType Hospital Course 100%053.3%Spelling mistakes, Short forms, Incomplete, Missing words Hospital Consults 100%020%Secondary consultant missing Hospital Procedures 93.3%6.7%13.3%Short forms, Absent Summary of relevant investigations 6.7%93.3 % Absent

OPERATIVE NOTES YesNoErrorsType Surgeon Details 93.3%6.7% Absent Anaesthetist Details 93.3%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 YesNoErrorsType Patient's health status on discharge 93.3%6.7% Absent

PATIENT/FAMILY INSTRUCTIONS (AS APPROPRIATE) YesNoErrorsType Discharge medications 100%073.3%Incomplete, Short forms, Spelling mistakes Activity/ Therapy orders 13.3%86.7% Absent Dietary instructions 26.7%73.3% Absent Plans for medical follow up 100%06.7%Incomplete

ATTENDING PHYSICIAN’S SIGNATURE YesNoErrorsType Signature of the Consultant 100%00 Signature of the Resident 86.7%13.3%60%No Name

EMERGENCY CONTACT NUMBERS YesNoErrorsType Contact Number 100%00

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 ( 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.

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