QUALITY OF DISCHARGE SUMMARY IN VARIOUS DEPARTMENTS OF A TERTIARY CARE HOSPITAL

Abstract

Background: Aims and objectives of this audit were to find out whether all the criteria of discharge summary outlined in modified Van-Walraven et al 1999 were met in the discharge summary of various department of Tribhuvan University Teaching Hospital (TUTH) and to determine the completeness of the discharge summary.

Methods: This audit was carried out in TU Teaching Hospital, Maharajgunj, Kathmandu, Nepal. Eight departments (Medicine, Surgery, Gynecology, Pediatrics, ENT-HNS, Orthopedics, Ophthalmology&Psychiatry) were included. 24 discharge summaries from April 2015 to March 2016 were analysed from each eight departments. Discharge summaries were selected by systematic random sampling (Discharge summary of 1st and 3rd week were randomly selected). Discharge summaries were analysed and compared with previous audit of 2015. Modified Van-Walraven criteria-ten points were evaluated in discharge summary.

Results: In this study Department of ENT – HNS showed the best discharge summary as per modified VanWalraven criteria whereas department of Orthopedics had the least inclusion of criteria. Regarding completeness of hospital discharge summary form, Department of ENT and HNS had the highest number of almost completely filled discharge summaries (>90%) followed by department of medicine.

Conclusion: Discharge summary should be filled up completely, clearly and without missing necessary information. Regular audit should be performed to ensure the quality of discharge summary.

Keywords: audit, Modified Van Walraven Criteria, Quality of discharge