AUDIT ON DISCHARGE SUMMARIES

1. AUDIT ON DISCHARGE SUMMARIES DR NIRANJAN P DR K LAKSHMAN DR M S SRIDHAR

2. Primary documents communicating a patient’s care plan to the post-hospital care team • Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care. • High-quality discharge summaries are essential for promoting patient safety during transitions between care settings Kind AJH, Advances in Patient Safety, 2008

3. The Joint Commission has established standards outlining the components that each hospital discharge summary should contain • Components are: • 1.Reason for hospitalization. • 2.Significant findings. • 3.Procedures and treatment provided. • 4.Patient’s discharge condition. • 5.Patient and family instructions (as appropriate). • 6.Attending physician’s signature. Kind AJH, Advances in Patient Safety, 2008

4. No clear and specific definition exists in the published literature for these components. • Additionally, it is not clear to what extent these standards are met in hospital discharge summaries • The present audit was carried out to compare the status and standard of our discharge summaries when compared to Joint commission standards Kind AJH, Advances in Patient Safety, 2008

5. Audit was carried out after designing a protocol and then analyzing our discharge summaries from the month of January to June 2013 • Total number of discharge summaries audited -374

11. REASON FOR HOSPITALIZATION

12. SIGNIFICANT FINDINGS

13. PROCEDURES AND TREATMENT PROVIDED

14. OPERATIVE NOTES

15. PATIENT’S DISCHARGE CONDITION

16. PATIENT/FAMILY INSTRUCTIONS (AS APPROPRIATE)

17. ATTENDING PHYSICIAN’S SIGNATURE

18. EMERGENCY CONTACT NUMBERS

19. DISCUSSION • Discharge summaries included all 6 of the joint commission recommended components • Majority of the errors may not be significant clinically • Errors in discharge medications could lead to potential clinical as well as medicolegal implications • Majority of them can be overcome by inclusion of templates

20. Most (88-100 percent) discharge summaries included five of the six Joint Commission components. • The remaining component, “patient’s discharge condition,” was included the least often (79-90 percent) Kind AJH, Advances in Patient Safety, 2008

21. RECOMMENDATION • To include templates on • Activity • Consults • Therapy • Discharge Medications • Names of the Residents • To educate the residents • Including the template for Referral doctor may be helpful for post discharge care delivery

22. CONCLUSION • Overall, discharge summaries adhere well to Joint Commission discharge summary component standards. • Even a small frequency of errors in information provided is a concern and may affect patient safety.

23. THANK YOU