An audit of discharge summaries from secondary to primary care

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 changed in 39% (n= 24). Details of the person completing the discharge summary were incomplete as follows: 85% (n= 52) had no specialty documentation, 36% (n= 22) had no registration number and 38% (n= 23) had no contact number. This audit shows deficits in adhering to HIQA standards. These must be addressed as a matter of urgency.