Assessment of hospital inpatient discharge summaries, written for general practitioners, from a department of medicine for the elderly service in a large teaching hospital.

BACKGROUND

The discharge document summarising an acute inpatient stay in hospital is often the only means of communication between secondary and primary care. This is especially important in the elderly population who have multiple morbidities and are often on many medications.

AIMS

This study aimed to assess if information important to general practitioners is being included in inpatient hospital discharge summaries for patients of the medicine for the elderly service in a large teaching hospital.

METHODS

After a thorough literature review, a "gold standard" letter was defined as having included a discharge diagnosis, medications on discharge and follow-up plans. Forty computerised discharge summaries were retrospectively assessed for inclusion of these parameters. The study group consisted of the first eight sequentially discharged patients under the care of each of the five consultants during a 1-month period (1 September 2011-30 September 2011).

RESULTS

A discharge diagnosis was included in 37 of the 40 summaries (92.5 %), medications on discharge were included in 39 summaries (97.5 %) and follow-up was recorded in 35 summaries (87.5 %).

CONCLUSIONS

This study showed that the information assessed was available in the vast majority of discharge summaries for patients admitted acutely under the care of this medicine for the elderly service. Improvements can be made, including documentation of follow-up plans.