Análisis de la fiabilidad de los informes de alta en un servicio de cirugía general

[Quality of hospital discharge reports in terms of current legislation and expert recommendations]

OBJECTIVE

To determine the quality of hospital discharge reports (HDRs) taking into account current legislation and the conclusions of the consensus on hospital discharge reports in medical specialities in 11 community hospitals in Andalusia (Spain).

MATERIAL AND METHODS

A cross-sectional study of 1,708 HDRs was carried out. We determined the presence or absence of the various items required by current legislation and by the recommendations of the above-mentioned consensus.

RESULTS

A total of 97.4% (95% confidence interval [95% CI]: 96.5-98.2) of the HDRs were classified as satisfactory according to the stipulations of current legislation. However, when the assessment was based on the consensus, the rate of adequacy fell to 72.1% (95% CI: 70.0-74.3). A notable finding was the absence of the duration of treatment after hospital discharge in 39.4% of the HDRs.

CONCLUSIONS

HDRs show an excellent level of compliance with the data required by current regulations, but their intrinsic quality needs to be improved.

[Extensive normalization of the surgical discharge report. An efficient quality alternative]

OBJECTIVE

To improve the quality of the clinical information documents received by surgical patients when discharged from the Hospital.

MATERIAL AND METHODS

A preliminary analysis of the quality of the surgical discharge form (SDF) included information regarding the time of issue (provisional vs. definitive), legibility/standardization (typewritten, hand-written with or without a standardised format), technical quality (complete vs. incomplete) and retrievability (electronically storage or not). This analysis showed that 39% of the forms were either provisional, incomplete or were standardised formats (59%) or hand-written as a simple medical note (41%). We have redesigned the methodology for filling in the SDF and their storage using the resources available in our Hospital. We designated a common surgical secretary to fill in all the SDF and designed 81 standard formats in Word for all the surgical procedures. A consensus protocol was also developed with the different surgical departments for the completion, distribution and monitoring of the SDF. Finally we established a Windows-based computerised system for centralized storage/retrieval of the discharge forms that could be easily accessed by internet.

RESULTS

All the SDF are standardised and electronically stored. The patient receives a typewritten form at the time of discharge. The dates for the first surgical or outpatient review are included in 98% of the SDF from hospitalised patients and in 100% of the SDF from major ambulatory surgery patients. We did not reach the expected outcome for minor surgical procedures.

CONCLUSIONS

The extensive standardisation of the SDF, together with the new methods for completing them, has shown to be an efficient measure to maximise the quality of the clinical information given to the patient and to minimise the waiting time from the physician confirming discharge to the patient eventually leaving the hospital.