Standardizing discharge summaries for improved communication and better patient care: a quality improvement project in a public sector tertiary care hospital in pakistan.

Quality improvement project

Abstract

Background :Discharge summaries (DS) serve as a critical communication tool between healthcare providers and patients. However, inconsistencies in documentation can lead to poor patient understanding, medication errors, and increased readmissions. An initial audit at our tertiary care hospital revealed that only 55% of discharge summaries contained complete and standardized information. Missing details included medication changes (40% missing), follow-up plans (35% missing), and pending investigations (50% missing). This project aimed to standardize discharge summaries in accordance with the Royal College of Physicians (RCP) guidelines to improve completeness, clarity, and patient outcomes.

Aim & Objectives: To increase the completeness of discharge summaries from 55% to 90% within three months and Improve documentation of key clinical details (primary/secondary diagnosis, procedures, and hospital course).Ensure medication changes and allergy documentation are consistently recorded.Enhance clarity of post-discharge management plans, follow-ups, and pending investigations.

Methods:The study followed a Plan-Do-Study-Act cycle, conducting two audit cycles at Ayub Teaching Hospital. The first audit cycle reviewed 310 discharge summaries (DS), while the re-audit was conducted after an educational intervention during monthly round meeting, analysing 185 DS. The completeness of DS was assessed using predefined parameters, and improvements were analyzed using the Chi-squared test and effect size (Cramer’s V).

Results:The findings revealed several shortcomings, with major gaps in recording pending investigations (50% compliance), findings of relevant investigations (50% compliance), and overall readability (55% compliance). Additionally, hospital course and procedures were documented in only 60% of cases, while changes to patients' medications were highlighted in just 60% of discharge summaries. Allergies were recorded in only 70% of cases, posing a potential risk to patient safety. On the other hand, some areas, such as patient identification (95% compliance) and documentation of primary and secondary diagnoses (85% compliance), were relatively well-maintained. These deficiencies underscored the need for a standardized discharge summary format to ensure clarity, accuracy, and continuity of care for patients after discharge.

Conclusion:The first audit cycle revealed deficiencies in DS completion and quality in several areas, including changes to medication, follow up plan, recording of allergies and legibility. Following the educational intervention, a significant improvement was observed in all these domains. Such projects highlight the importance of regularly conducting clinical audits to improve discharge summaries to enhance patient outcomes and clinical communication.

Keywords: Discharge Summary, documentation completeness, patient safety, clinical communication, hospital audit, tertiary care hospital, medical record improvement.