An audit of discharge summaries from secondary to primary care.

BACKGROUND: Health is information-intensive. Reliable health care depends on access to this information in a timely and accurate manner. A standardised data set for clinical discharge summaries is essential to optimise the care the patient receives, particularly at discharge. The Irish Health Information and Quality Authority (HIQA) have recently developed a national standard for patient discharge summaries.

AIMS: Our aim was to assess the current quality of discharge summaries being received, determine the main areas of concern and establish the areas to improve patient safety.

METHODS: We studied 60 discharge summaries received at 3 general practices in the Mid-West of Ireland. We used HIQA "National Standard for Patient Discharge Summary" 2013 as our audit standard.

RESULTS: Mandatory fields including Surname, Forename and date of birth were present in 100%, missing in 0%. The patient's address was missing in 7% (n = 4). Gender was missing in 82% (n = 50). Source of referral was missing in 52% (n = 32). No method of admission was documented in 70% (n = 43). Whilst principal diagnosis was documented in 100% (n = 60), no co-morbidities were documented in 28% (n = 17). No medication was documented in 30% (n = 18), and there was no documentation of medication changed in 39% (n = 24). Details of the person completing the discharge summary were incomplete as follows: 85% (n = 52) had no specialty documentation, 36% (n = 22) had no registration number and 38% (n = 23) had no contact number.

CONCLUSIONS: This audit shows deficits in adhering to HIQA standards. These must be addressed as a matter of urgency.