WTP6.13 A closed loop audit on the Quality of Electronic Discharge Summaries within General Surgery

Abstract

Abstract Aim Following surgical admissions, Electronic Discharge Summaries (EDS) are vital to ensure patient safety through continuity of care to the primary care setting. It is also an official record to the patient about the treatment and care they received including any further treatment or follow up appointments they require and is therefore important they are not only accurate but detailed with all the relevant information included. Methods An audit of Electronic Discharge Summaries within a busy Emergency General Surgery department was undertaken using a gold standard which was established by using the 20 most important parameters within the standardized proforma. If a discharge summary had 80% or more parameters sufficiently completed it was deemed to be adequate. A first and second cycle of data collection of 100 EDS’s were undertaken and analysed using the gold standard criteria. Results A first cycle data collection of 100 EDS’s were analysed, it was found only 55% of these were adequate following the standard set. An educational teaching session to doctors at a local meeting was carried out to explain why 45% of the discharge summaries were not complaint with the standard set. The second cycle showed 91% of EDS’s to be of adequate standard. Conclusion This audit has shown that adhering to a gold standard template can significantly improve the quality of discharge summaries. A re-audit in 12 months should be carried out to ensure standards have been maintained.