Audit of ophthalmology discharge summaries in a Nigerian Teaching Hospital

Abstract

Background: Discharge summaries are important components of hospital‑care transitions in ensuring continuity of care.

Aim: We assessed the adequacy and accuracy of discharge summaries written by junior doctors.

Methods: An instrument, adapted largely from the current hospital discharge summary template and recommendations regarding content from the Joint Commission International, was used to study 420 discharge summaries written in 2012 from the ophthalmology service of a Rural Teaching Hospital in Nigeria. The simple descriptive analysis was done with Statistical Package for the Social Science version 17.

Results: Completeness of entries was relatively high in many traditional areas (biodata of patient, admission/discharge dates, name of supervising consultant, principal diagnosis, surgical procedures done, follow‑up instructions, and condition on discharge) of the summaries. The portion of the paper‑based template titled “summary” of the admission was most problematic; with information on medication changes and result of tests missing in 368/420 (87.6%) and 334/420 (79.5%), respectively.

Conclusion: Educational intervention for doctors in training with the provision of oversight and feedback by their supervisors is required. Standardized discharge summary templates recognizing the peculiarities of specialized patient groups are recommended. Transition to electronic discharge summary system is imperative.

Keywords: Audit, discharge summaries, ophthalmology, teaching hospital