DR NIRANJAN P DR K LAKSHMAN DR M S SRIDHAR AUDIT ON DISCHARGE
SUMMARIES
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Primary documents communicating a patients 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
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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.Patients discharge
condition. 5.Patient and family instructions (as appropriate).
6.Attending physicians signature. Kind AJH, Advances in Patient
Safety, 2008
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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
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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
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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
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
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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
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PATIENTS DISCHARGE CONDITION YesNoErrorsType Patient's health
status on discharge 93.3%6.7% Absent
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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
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ATTENDING PHYSICIANS SIGNATURE YesNoErrorsType Signature of the
Consultant 100%00 Signature of the Resident 86.7%13.3%60%No
Name
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EMERGENCY CONTACT NUMBERS YesNoErrorsType Contact Number
100%00
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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
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Most (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, 2008
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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
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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.