Auditing of discharge summaries Contet at Al Amal medical complex

Abstract

Introduction and aims

Patient's records are the most important clinical assets and tools which are required in consultations. Patient records also support the accurate continuity of care when patients return to other health providers.

Objective

Understand the extent of Discharge Summaries, which conform to the set best practise guidelines on the Mental Health Service.

Method

A cross-section retrospective study on Discharge Summary contents was conducted at Al Amal Medical Complex. Chart review of randomly selected patient files (200 of a total 495), of Discharge Summaries for Psychiatric Patients in 2014 was performed. The data was statistically analysed using descriptive statistics taking into account proportions and frequencies. Pearson chi square and Fisher's test methodologies were used.

Result

This study found of the 200 randomly selected Discharge Summaries that documented data of mental health examination 94% (n = 188), data of discharge date 100% (n = 200) while data of social investigation and family work up 82% (n = 164). The above three categories were the only categories to conform to standard discharge guidelines. The other thirteen items studies were found not conforming to the defined standard guidelines.

Conclusion and recommendation

There is an active challenge for clinicians to introduce good clinical practice in Mental Health. Standard guidelines must be followed by clinician's in order to reduce potential areas of concern and achieve a good clinical practise. Regular recurring audits are highly needed& recommended to ensure the alignment with standard guidelines for the writing of Discharge Summaries.

Disclosure of interest

The author has not supplied his/her declaration of competing interest.