RESUMO
Introduction Discharge summaries (DS), which are sent from inpatient to outpatient settings, transmit critical clinical information. DS play a crucial role in the discharge process since they provide critical information about the patients that is simple to remember and help with patient follow-up in the community. This audit sought to determine if a quality improvement (QI) program may have an influence on the severity of mistakes at the moment of discharge and to assess the existing degree of inconsistencies on handwritten DS for orthopaedic patients. Methodology From the orthopaedics department at a tertiary care facility in south India, 100 handwritten DS and 100 electronic DS over six months were randomly chosen, and they were retrospectively audited against a predetermined set of criteria. The errors were compiled and compared by three reviewers. Results Some of the criteria, such as the doctor's signature, the speciality of admission, procedural therapy at the hospital, and the date of admission, were contained in all handwritten and electronic DS. Some of the metrics showed that electronic DS performed better than handwritten DS in areas such as hospital complications, which increased from 50% to 100%, contact information, which increased from 34% to 95%, and condition at discharge, which increased from 66% to 96%. Also, understandability increased from 58% to 100%, prognostic details increased from 70% to 96%, allergies increased from 66% to 100%, physical examination findings increased from 88% to 100%, admission diagnosis increased from 80% to 100%, patient/physician details increased from 92% to 100%, the information given to patient increased from 88% to 100%, problem list/issue pending increased from 35% to 92%, investigation increased from 80% to 100%, discharge medications increased from 88% to 100%, follow-up plan increased from 80% to 100%, discharge diagnosis increased from 94% to 100%, International Classification of Diseases, Tenth Revision (ICD-10) code increased from 93% to 100%, and days of admission increased from 92% to 100%. Conclusion Following the deployment of electronic DS, we were able to better care for patients and lessen their discomfort. We advise converting to electronic DS to enhance patient care and better record-keeping since this will become a significant problem if all notes are not accurately filled and are not readable.
