Surgical discharge summaries: improving the record

• Published in: Annals of the Royal College of Surgeons of England Vol. 75; no. 2; pp. 96 - 99
• Main Authors: Adams, D C, Bristol, J B, Poskitt, K R
• Format: Journal Article
• Language: English
• Published: England Royal College of Surgeons of England 01.03.1993
• Subjects: Attitude of Health Personnel; Computers; England; Humans; Management Audit; Medical Records; Patient Discharge; Physicians, Family - psychology; Surgical Procedures, Operative; England
• ISSN: 0035-8843; 1478-7083

The problem area of communication between hospital and general practitioners may potentially be improved by the advent of new information technology. The introduction of a regional computer database for general surgery allows the rapid automated production of discharge summaries and has provided us with the opportunity for auditing the quality of old and new styles of discharge communication. A total of 118 general practitioners were sent a postal questionnaire to establish their views on the relative importance of various aspects of patient information and management after discharge. A high response rate (97%) indicated the interest of general practitioners in this topic. The majority (73%) believed that summaries should be delayed no more than 3 days. The structured and shortened new format was preferred to the older style of discharge summary. The older format rarely arrived within an appropriate time and its content was often felt to be either inadequate (35%) or excessive (7%) compared with the new format (8% and 1%, respectively). The diagnosis, information given to the patient, clinic date, list of medications and investigations were considered the more important details in the summary. Improvements in the discharge information were suggested and have subsequently been incorporated in our discharge policy. The use of new information technology, intended to facilitate clinical audit, has improved our ability to generate prompt, well-structured discharge summaries which are accepted by the general practitioners.