ThTP6.9 Assessing the Quality & Completeness of Discharge Summaries

Abstract

Abstract Objective A review of the timeliness, accuracy, and completeness of surgical discharge summaries. Aims To assess whether discharge summaries are sent within 24hours of discharge and if they contain accurate information for the patient and the GP in terms of case summary, follow up plans and post-operative instructions. Methods Patients admitted under General Surgery/Urology at a DGH during February and May 2022 were identified. 162 patients were identified, and a random sample of 45 patients was analysed. The discharge summary was compared to inpatient notes and rated against a pre-determined standard including accuracy of operative details, use of patient friendly language and safety netting advice. Data was collected by two independent doctors. Results 43/45 (96%) of discharge summaries were completed on the day of discharge. 44/45 completed operative details which was accurate in 40/44. 83% specified a follow up plan. 50% described a follow up investigation, but these were only requested in 33% of cases. When relevant, instructions regarding stitches were given in 38% of cases, wound care instructions in 0% and in 50% instructions were given regarding indwelling drains. Overall, 51% of summaries were rated as using patient friendly language. 22% had inadequate safety netting advice. Conclusions Overall, discharge summaries were completed within 24hours. The use of patient friendly language, safety netting advice and post-operative instructions needs improvement. It is important that ongoing investigations are requested at the time of discharge to avoid delays or omissions in patient care. We recommend additional training for rotating doctors at induction and propose a discharge template for common surgical conditions.