The quality of discharge summaries completed in the general paediatric wards at the Chris Hani Baragwanath Academic Hospital

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dc.contributor.authorSingh, Shire Karan
dc.date.accessioned2018-07-09T10:45:16Z
dc.date.available2018-07-09T10:45:16Z
dc.date.issued2017
dc.descriptionA 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.en_ZA
dc.description.abstractBackground: 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.en_ZA
dc.description.librarianLG2018en_ZA
dc.identifier.urihttps://hdl.handle.net/10539/24822
dc.language.isoenen_ZA
dc.subject.meshPediatrics
dc.subject.meshPatient Discharge Summaries
dc.titleThe quality of discharge summaries completed in the general paediatric wards at the Chris Hani Baragwanath Academic Hospitalen_ZA
dc.typeThesisen_ZA
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