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Analysis Study Research Paper | Surgery | India | Volume 13 Issue 11, November 2024 | Popularity: 5.4 / 10

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Assessment the of Quality of Discharge Summaries for Elective and Emergency Surgical Procedures at a Government Medical College Hospital in India

Poorna Prasad, Rajalakshmi G

Abstract: Aim: The aim of this study is to evaluate and compare the quality and completeness of handwritten versus electronic discharge summaries and to identify strategies for improving documentation and patient information transfer. Objectives: 1) To assess the quality and completeness of handwritten versus electronic discharge summaries 2) To explore how the format of discharge summaries (handwritten vs. electronic), particularly the use of standardized templates, affects their completeness 3) To propose strategies for enhancing discharge summary practices aimed at improving documentation quality, reducing errors, and ensuring effective patient information transfer. Methods: This 4 - month retrospective comparative study, conducted from June to September 2024, assessed the quality and completeness of handwritten versus electronic discharge summaries (DS) for patients undergoing elective surgeries in a surgical department. A total of 200 DS were analyzed: 100 handwritten and 100 electronic, chosen through random sampling. The analysis included systematic review - based criteria and additional institutional parameters like surgery date, implant status, and intraoperative findings. Data collection involved reviewing handwritten summaries and electronic records from the hospital's system. Inclusion criteria encompassed DS of patients admitted for elective surgeries, including discharges against medical advice. Exclusions included DS for non - specified surgeries and cases of in - hospital deaths. Data were collected from the hospital's electronic health record system and manually reviewed for the handwritten summaries and descriptive and exploratory analysis was done. Results: Both electronic and handwritten discharge summaries (DS) consistently include doctor sign summary, specialty of admission, date of admission/discharge, and procedure treatment at a 100% rate, demonstrating strong documentation practices. However, discharge diagnosis is fully recorded in electronic DS but less so in handwritten DS. The absence of a dedicated heading for ICD - 10 codes in handwritten summaries leads to discrepancies, despite their easy inclusion in electronic templates. The date of surgery, present in electronic DS, is omitted in handwritten DS, affecting overall documentation. Understandability and hospital complications appear at a 76% rate in handwritten DS, while electronic DS achieve 100%. Critical patient details like prognostic information, discharge condition, and follow - up plans are better captured in electronic DS due to structured templates. Elements such as coping support, nursing comments, pain relief, and nutrition, while 100% in electronic DS, are absent in handwritten DS, likely due to missing template headings. Both formats neglect social issues, cultural considerations, and palliative care. Intraoperative findings are comprehensive in electronic DS but lacking in handwritten DS. Finally, implant/stent status is recorded at 45% in handwritten DS compared to 100% in electronic DS, underscoring the importance of structured documentation for complete data capture. Conclusion: This study highlights major documentation differences between handwritten and electronic discharge summaries, underscoring the importance of standardized electronic templates for clarity and patient safety. Recommendations include standardized templates, provider training, automated data integration, regular audits, and support tools. Multidisciplinary involvement and patient education can further improve documentation quality and continuity of care, ensuring better outcomes.

Keywords: Discharge Summary, Documentation Quality, Electronic Health Records (EHR), Patient Safety, Standardized Templates, Continuity of Care

Edition: Volume 13 Issue 11, November 2024

Pages: 651 - 655

DOI: https://www.doi.org/10.21275/SR241103195933

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