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Discharge summaries: One size does not fit all
  • Yagmur Esemen,
  • Micaela Uberti,
  • Navneet Singh
Yagmur Esemen
St George's Hospital Atkinson Morley Regional Neuroscience Centre

Corresponding Author:[email protected]

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Micaela Uberti
St George's Hospital Atkinson Morley Regional Neuroscience Centre
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Navneet Singh
St George's Hospital Atkinson Morley Regional Neuroscience Centre
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Abstract

A discharge summary is a permanent record of a patient’s hospital visit and the primary means of handover between care providers, but they often lack precision and omit important information. The aim of this study was to develop the ‘ideal’ discharge summary for patients in a regional neurosurgical centre. The essential elements were identified by discussion with clinicians within the department of neurosurgery and summaries were retrospectively audited against these. We then put in place two interventions: a visual aid outlining key components was placed above computer stations in the junior doctors’ offices and formal departmental teaching sessions delivered. After three months we re-audited the discharge summaries retrospectively. Initial audit identified poor documentation especially of medical issues during hospital admission, clinical condition on discharge and safety-netting. After the interventions, documentation in all key components improved dramatically. Good documentation is one of the most important non-clinical aspects of medical practice yet, it is not always part of under-graduate and post-graduate education. Existing guidelines about writing good discharge summaries exist but these are vague and not specific to specialist practice. The development of a simple specialty specific discharge summary guide can improve discharge summary quality and should be encouraged in all specialties.