ABSTRACT

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.