Quality of Discharge Summary in Various Departments of a Tertiary Care Hospital: A Roll-On Audit

Abstract

Aims and Objectives: Discharge summaries are essential communication tools between hospital-based and community-based healthcare providers. A previous audit at Tribhuvan University Teaching Hospital (TUTH) in 2016 assessed the quality of discharge summaries across departments using the modified Van Walraven criteria. This roll-on audit aims to re-evaluate the quality and completeness of discharge summaries and assess improvements since the last audit. To determine whether discharge summaries across various departments at TUTH in 2023-24 meet the standards outlined by the modified Van Walraven et al. (1999) criteria, and to assess the completeness of documentation.
Methods: This audit was conducted at TU Teaching Hospital, Kathmandu, Nepal, between April 2023 and March 2024. Seven departments were included: Medicine, Surgery, Gynecology, Pediatrics, ENT-HNS, Orthopedics and Psychiatry. A total of 168 discharge summaries (24 from each department) were selected through random sampling. Each summary was evaluated based on the ten-point modified Van Walraven criteria and compared with results from the 2016 audit.
Results: The Department of ENT-HNS demonstrated the highest level of completeness, with 99.5% of discharge summaries fully filled, while the Medicine department had the lowest completion rate at 94.0%. Frequently omitted components across all departments included physical examination findings and laboratory investigation results.
Conclusion: The roll-on audit demonstrates positive trends in discharge summary quality at TUTH. However, variability persists across departments. Regular audits, staff training, and standardized templates are recommended to further improve documentation practices and ensure high-quality patient care transitions.
Keywords: Audit, Discharge Summary, Modified Van Walraven Criteria