Authors (including presenting author) :
Wong TC (1)(2), Ng SC (1)(2), Wong WY (1)(2)
Affiliation :
(1) Department of Medicine, Haven of Hope Hospital
Introduction :
Hospital discharge summaries serve as an important document to communicate patient’s care plan between different healthcare teams. It helps to enhance continuity of care particularly the information continuity. There is lacking guideline or standards for writing a good hospital discharge summary in HA.
Objectives :
We conducted an audit in Haven of Hope hospital (HHH) to assess on how well our discharge summaries adhered to the 6 components of Joint Commission on the Accreditation of Healthcare Organizations. These 6 components were reasons for hospitalization, significant findings, treatment provide, patients’ discharge condition, patient/family instructions and physician’s signature. We aimed to identify any loopholes from our discharge summaries and suggested for any solutions to improve the quality and safety.
Methodology :
One hundred discharge summaries were randomly selected for review from 1st September 2021 to 30th June 2022. All patients were transferred to HHH from 2 acute hospitals of Kowloon East Cluster for management. Patients who were clinically admitted from our out-patient clinic for procedure or treatment were excluded. Patients who were died in the index admission were also excluded.
Result & Outcome :
Result: Among the 100 screened discharge summaries, 85 had fulfilled all the Joint Commission mandated components, while 15 discharge summaries missing component. Fourteen of them had a missing component in “patient’s discharge condition”, and 1 had missed the “Reason for hospitalization”. Higher percentage of discharge summaries with missing component were written by basic physician trainee(BPT) (17.6%) compared to Higher physician trainee (HPT) (8.7%). We also observed that 12% of discharge summaries had > 6 pages. Conclusion: Most of the discharge summaries met all the Joint Commission components. “Patient ‘s discharge condition” was most often being omitted component. Training on writing discharge summary for doctors especially during their internship or first year after graduation may improve the quality of discharge summary. The implication on the quality and safety in hangover the case with lengthy discharge summary required further study.
