The quality of discharge summaries completed in the general paediatric wards at the Chris Hani Baragwanath Academic Hospital
Date
2017
Authors
Singh, Shire Karan
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Abstract
Background: Hospital discharge summaries are deemed to be an essential part of the medical
record in South Africa but a formal assessment of the quality of these summaries is rarely
undertaken. At the Chris Hani Baragwanath Academic Hospital (CHBAH), medical admission
notes (bedletters) are difficult to retrieve from the hospital archives and the discharge summary
is often the only readily available medical record that documents details of the hospital
admission.
Objectives: This study determined the proportion of discharge summaries that are
appropriately completed for children admitted to the general paediatric wards at CHBAH in
Soweto.
Methods: A retrospective review of discharge summaries completed for children admitted
from 01 May to 31 July 2016 was undertaken. The completeness of the following demographic
and clinical variables was assessed: patient identifiers, hospital outcome, HIV infection status,
and anthropometric status. The documentation of correct ICD-10 codes was assessed in
children who were diagnosed with any form of lower respiratory tract infection (LRTI), which
is the commonest diagnosis recorded in hospitalised children at CHBAH.
Results: Discharge summaries were available for 1148 (78.3%) of 1466 children admitted
during the study period. For completed discharge summaries, between 80.1% to 93.3% of
patient identifiers and 91.4% of patient outcomes were appropriately completed. HIV-exposure
was documented in 84.7% of summaries. The anthropometric parameters, including admission
weight and length/height, and discharge weight, were appropriately completed in 91.4%,
70.9%, and 50.0% of summaries respectively. The ICD-10 code for children with LRTI was
appropriately recorded by medical staff in 338 (67.2%) of 503 cases. ICD-10 codes and
anthropometric parameters, which are important clinical parameters in the paediatric followup
consultation, were both correctly recorded in only 21.6% of children who required followup
clinical consultations at CHBAH.
Conclusion: Compared to similar studies, both the rate of completion and the quality of
completed discharge summaries were modest in this tertiary academic teaching hospital. As
discharge summaries are crucial medical documents, interventions to improve the
completeness rate and quality of discharge summaries need to be developed.
Description
A research report submitted to the Faculty of Health Sciences, University of the
Witwatersrand, in partial fulfilment of the requirements for the Degree Masters of Medicine. 17 November 2017.