Suggestions for improvement Raise awareness and importance of writing discharge summaries and sending them by highlighting that delivering this information on time is part of effective health care and responsibility of the health care professional writingprinting summary ID: 931902
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ResultsConclusionsGood compliance with writing TTOs however there is room for improvement with adherence to filling in certain information parameters as per the national standard Suggestions for improvement:Raise awareness and importance of writing discharge summaries and sending them by highlighting that delivering this information on time is part of effective health care and responsibility of the health care professional writing/printing summaryHighlighting estimated date of discharge so discharge summaries can be done in a timely mannerModifications in extra med discharge format (e.g. add bleep no, why change medication) as mandatory requirements to ensure that information is filled in Having different sections for different categories of healthcare professionals e.g. A separate section for OT/PT/Dietitians so they can add their inputRe audit to continue the quality improvementBy doing this, trusts will take a step towards achieving their Commissioning for Quality and Innovation targets and will ensure that patients and GPs are better informed about their care and any after care needed.In the long term, this will improve the information provided to patients and create a better way of patients and GPs working together in an informed manner, and in turn could result in a reduction of readmissions.References“Electronic 24hr discharge summary implementation”, Clinical record standards. Health and Social care information centre. (http://systems.hscic.gov.uk/clinrecords/24hour) Accessed 10/10/2014
AbstractA standardised electronic discharge summary enables the continuous care of patients once they have been discharged from hospital, with consistent and relevant information in the right place in a timely manner. The Clinical Data Standards Assurance programme began a project to deliver a national, clinically-assured electronic discharge summary to the GP within 24 hours of the patient being discharged from hospital. The aim of this audit was to assess compliance of the acute medical wards to the nationally-agreed discharge summary headings as approved by the Royal College of Physicians professional record keeping standards work published by the Academy of Medical Royal College. IntroductionIn August 2010, the Clinical Data Standards Assurance programme began a project to deliver a national, clinically-assured electronic Discharge Summary to the GP within 24 hours of the patient being discharged from hospital. This discharge summary was intended to be structured, standardised and generic thus, having the ability to be sent electronically from any acute hospital electronic health record system. Discharge summaries are a means to deliver effective health care by sharing accurate, valid and critical patient information with the general practitioners in a timely fashion. The inability to share information leads to unnecessary duplication of tests and delays in patients receiving appropriate treatment with potentially serious consequences which threaten both the patient safety and quality of care being provided. This aim of this project was to look at local practice by reviewing the discharge summaries being issued from acute medical wards to assess if we are achieving the targets set by the Clinical Data Standards Assurance Programme in delivering complete and accurate information that meet the needs of the GP and patient. MethodologyAudit standards: The Royal College of Physicians professional record keeping standards work published by the Academy of Medical Royal College discharge summary headings. A questionnaire was designed using the audit standard which focused on the following headings:TTO Done or notDate of Discharge documentedText satisfactoryPresentationInvestigationDischarge DestinationDiagnosisAllergies documentedMedication On DischargeAny medication changes documented clearlyAny medication stopped documented clearlyFollow upSender nameBleep/Contact noJob titleIf patient died –was GP informedTTO Send lateThe sample comprised of cross checking medical discharge summaries from acute care wards in Broomfield Hospital over a fixed period in patients whose length of admission was > 24 hours. Data was collected prospectively.
Electronic 24-hour discharge summary
National Standard for Patient Discharge Summary Information
Health Information and Quality Authority
Dr H. Iftikhar, Dr S. Saber, Dr B. Band, Dr A. Qureshi Department of Elderly care, Broomfield Hospital Mid Essex Hospital NHS Trust
INITIAL AUDIT
QUALITY IMPROVEMENT
YES
NO
YES
NO
TTO DONE
92%
8%
94%
6%
DATE OF DISCHARGE DOCUMENTED
68%
32%
94%
6%
TEXT SATISFACTORY
89%
11%
94%
6%
PRESENTATION
93%
7%
94%
6%
INVESTIGATION
89%
11%
90%
10%
DISCHARGE DESTINATION
83%
17%
94%
6%
DIAGNOSIS
76%
24%
78%
22%
ALLERGY DOCUMENTED
76%
24%
74%
26%
MEDICATION DISCHARGE
72%
20%
92%
2%
MEDICATION CHANGE DOCUMENTED
23%
26%
92%
2%
MEDICATION STOPPED DOCUMENTED
13%
21%
90%
4%
FOLLOW UP
69%
31%
80%
20%
SENDER NAME
93%
7%
98%
2%
BLEEP NO
1%
99%
2%
98%
JOBTITLE
93%
7%
98%
2%
PATIENT DIED GP INFORMED
0%
2%
0%
0%
TTO SEND LATE
16%
14%
TTO done but not sent = 22
%