Assessment of discharge summaries in the patients’ health records at a public tertiary hospital in North-Central Nigeria

Abstract

Background/Objectives: Discharge summary is an essential documentation tool in the patients’ healthrecords that recapitulate the very essence of seeking care. It is the most versatile communication tool inthe patients’ health records. The quality of documentation in the discharge summaries is waning andthere are recorded cases of gross under-utilization of the summaries, illegible documentation andrecurrent record deficiencies in the patients’ health records. Design/Methods: The study was aretrospective review of health records of inpatients discharged in the hospital between 1st January andDecember 31st 2015. A health records review form adapted from WHO was used to assess the quality of discharge summary. Results: Most of the inpatient health records were found without completed discharge summary form, whereas the majority of these records were clinically coded. Conclusion: The challenges of gross under-utilization of discharge summaries persists in the index hospital even after aten years gap of a data quality study in the hospital. Attitude of physicians toward clinical documentation tends to threaten effective communication among care givers and as a result, maynegatively affect care process and service delivery to the teeming patients. The study therefore recommends institutionalization of clinical documentation improvement program, training and retrainingof all healthcare providers on the imperatives of quality documentation.Keywords: Clinical documentation; Data quality; Health data; Discharge summary; Patients health records