1364 Quality Control of Discharge Summaries for Endocrine Surgery Patients; A Closed Loop Audit

Abstract

Abstract Aim A patient's discharge summary (TTO) should be accurate. Most of them are conducted by junior doctors at the beginning of their medical training. The information mentioned in a TTO ensures patient safety, continuity of care as well as correct clinical coding for the NHS. Therefore, a re-audit was designed to check the quality of the discharge summaries of endocrine surgical patients In Nottingham City Hospital i.e., the type of operation, diagnosis, or postoperative instructions. Method The first cycle included all the TTOs for the endocrine surgical patients operated from April 2018 to November 2018. Then we re-audited those who had endocrine surgeries from April 2019 to November 2019. NOTIS e-TTO, Bluespier theatre lists and Medway were used to retrieve the data. All general surgery patients were excluded. Results 142 and 104 patients TTOs were included in each audit cycle, respectively. Type of operation was improved from 84% to 95% in the second cycle. Correct diagnosis was reported from 68% to 72% in the second cycle audit. Conclusions The introduction of electronic operation notes in our practice improved the correct clinical coding for the type of operation mentioned in the TTO. The accuracy of correct diagnosis remains suboptimal. Therefore, education of junior doctors and an idea of double-checking from a more senior colleague should be assessed.