PubMed · 2013 · 71 citations · 0 references
Health ProfessionsHealth InformaticsAuditingHealthcare Quality ImprovementPatient SafetyClinical AuditDischarge DocumentationHospital DocumentationCompleteness Of Clinical DocumentationDischarge Summary ReportingPractice AuditReferral Completion Rates
BACKGROUND: Timeliness and quality of hospital discharge summaries are crucial for patient safety and efficient health service provision after discharge. METHODS: We audited receipt rates, timeliness and the quality of discharge summaries for 49 admissions among 38 patients in an urban general practice. For missing discharge summaries, a hospital medical record search was performed. RESULTS: Discharge summaries were received for 92% of identified admissions; 73% were received within three days and 55% before the first post-discharge visit to the general practitioner (GP). Administrative information and clinical content, including diagnosis, treatment and follow-up plans, were well reported. However, information regarding tests, referrals and discharge medication was often missing; 57% of summaries were entirely typed and 13% had legibility issues. DISCUSSION: Completion rates were good but utility was compromised by delays, content omissions and formatting. Digital searching enables extraction of information from rich existing datasets contained in GP records for accurate measurement of discharge summary receipt rate and timing.