Objective:

To assess the quality of documentation and the frequency of provision of discharge summaries to general practitioners (GP) for patients discharged from our emergency department (ED).

Material and Methods:

The ED records of 50 patients who presented to the ED and who had been discharged to self-care or the care of their GP on an arbitrarily chosen day were selected for auditing. A pre-formatted computerised discharge summary was then introduced to the ED and the first 50 consecutive electronic discharge summaries of patients who visited the ED were selected for auditing.

Results:

In the first audit cycle, a diagnosis was documented in 78% of cases. Documentation of key investigation results was present in 84% of cases. Documentation that a prescription was provided to the patient was present in 46% of cases. Documentation of appropriate follow-up care and self-care instructions was demonstrated in 68% and 50% of cases. Of those discharged to GP care, none had documentation that a GP letter was sent or a copy attached. Second cycle: GP correspondence letters were sent and a copy saved in all cases. A diagnosis, follow-up care plan and results of key investigations were documented in 100% of discharge summaries. Self-care instructions on discharge were documented in 94% of cases

Conclusion:

The introduction of electronic discharge summaries improved the quality and safety of the discharge process within our emergency department and paves the way for further improvements in information transfer technology.

Keywords: Communication, discharge summaries, documentation, electronic