67 Audit of discharge summaries on a geriatric ward against the Health Information and Quality Authority (HIQA) National Standard

Abstract

Abstract Background Discharge summaries are integral for safe transition of patient care. Complete, precise and succinct documentation can ensure improved quality of care and patient safety. Methods Retrospective data were collected from e-discharge summaries that were generated over a 7-month period from June-Dec 2022. A total of 20 samples were selected at random and assessed against the HIQA National Standard. The samples were compared to the physical medical records to countercheck if relevant information were present or omitted. There was a total of 78 outcomes measured as per the national standard. Results There were 8 (40%) discharge summaries with the complete clinical courses, in that they contained the main complaint, relevant clinical findings, relevant investigations results and the complete treatment courses. There were 4 (20%) summaries that had omitted documentation of inpatient complications or adverse events and 8 (40%) summaries had omissions present on medication prescriptions. There were 5 (25%) summaries whereby the list of stopped medications and the reasons for stopping the respective medications were omitted. There were 5 (25%) summaries with incomplete documentation of future plans. Only 4 (20%) discharge summaries had all the relevant information present. Conclusion Efforts to implement E-prescribing and electronic health records should be prioritised. The Irish Medical Council plans to introduce Entrustable Professional Activities (EPA), which are essential tasks that a trainee can be trusted to perform without direct supervision, once sufficient competence has been demonstrated. An entire EPA unit is dedicated to competent patient handover and discharge. A Discharge Summary Flowchart which highlights the inclusion of all the essential components of a complete discharge summary was introduced as a guide for the team. Finally, there is an ongoing continuous audit by Senior House Officers and Interns to assess the quality of discharge summaries after the recommendations have been implemented.