An audit of discharge summaries from secondary to primary care

Irish Journal of Medical Science
Ray O'ConnorUmbreen Salim

Abstract

Health is information-intensive. Reliable health care depends on access to this information in a timely and accurate manner. A standardised data set for clinical discharge summaries is essential to optimise the care the patient receives, particularly at discharge. The Irish Health Information and Quality Authority (HIQA) have recently developed a national standard for patient discharge summaries. Our aim was to assess the current quality of discharge summaries being received, determine the main areas of concern and establish the areas to improve patient safety. We studied 60 discharge summaries received at 3 general practices in the Mid-West of Ireland. We used HIQA "National Standard for Patient Discharge Summary" 2013 as our audit standard. Mandatory fields including Surname, Forename and date of birth were present in 100%, missing in 0%. The patient's address was missing in 7% (n = 4). Gender was missing in 82% (n = 50). Source of referral was missing in 52% (n = 32). No method of admission was documented in 70% (n = 43). Whilst principal diagnosis was documented in 100% (n = 60), no co-morbidities were documented in 28% (n = 17). No medication was documented in 30% (n = 18), and there was no documentation of medication chan...Continue Reading

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Citations

Apr 25, 2019·The British Journal of General Practice : the Journal of the Royal College of General Practitioners·Elaine K WalshPatricia M Kearney
Nov 2, 2019·Irish Journal of Medical Science·Conor CoyleYael Gelfer
Dec 1, 2020·International Journal of Integrated Care·Maria Raisa Jessica Ryc AquinoJonathan Mant

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