759 Electronic Discharge Summary Audit

Aim

Electronic discharge summaries (EDS) in General Surgery were found to be lacking adequate clinical information. The Professional Records Standards Body (PRSB) released guidance, endorsed by NICE, with the information required in an electronic discharge summary. The aim of the study was to monitor and record how many EDS’s have been completed with all the relevant/required sections completed.

Method

A retrospective analysis of EDS of 50 patients admitted under general surgery at Worcestershire Royal Hospital was conducted. Yes, No or N/A were marked against 13 categories based on PRSB guidelines. 4 cycles were carried out between 2020 to 2022.

After cycle 1, a poster was introduced outlining the criteria for electronic discharge summaries (Figure 1). A printed version of the poster was placed in the doctor’s office. After cycle 2, feedback was collected from junior doctors who suggested a teaching session on how to write electronic discharge summaries. A teaching session was delivered to junior doctors prior to cycle 3 and 4.

Results

The overall level of compliance for each cycle was as follows-Cycle 1- 8% complianceCycle 2- 22% complianceCycle 3- 34% complianceCycle 4- 69% compliance

Conclusions

The poster and teaching session proved effective at improving compliance.It was found there was poor compliance in completing the comorbidities section in the EDS. Acknowledging feedback from the junior doctors helped provide useful teaching sessions so we will continue regular teaching sessions. Continue annual audit of EDS' to increase compliance.