Singh S, Solomon F, Madhi S A, Dangor Z, Lala S G
Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
S Afr Med J. 2018 Oct 26;108(11):953-956. doi: 10.7196/SAMJ.2018.v108i11.12966.
Hospital discharge summaries are deemed to be an essential part of the medical record in South Africa, but formal assessment of their quality is rarely undertaken. At Chris Hani Baragwanath Academic Hospital (CHBAH) in Johannesburg, medical admission notes (bedletters) are difficult to retrieve from the hospital archives and the discharge summary is often the only readily available medical record that documents details of the hospital admission.
To determine the proportion of discharge summaries that were appropriately completed for children admitted to the general paediatric wards at CHBAH.
A retrospective review of discharge summaries completed for children admitted from 1 May to 31 July 2016 was undertaken. The completeness of the following demographic and clinical variables was assessed: patient identifiers, hospital outcome, HIV infection status and anthropometric status. The documentation of correct International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes was assessed in children diagnosed with any form of lower respiratory tract infection (LRTI), which is the commonest diagnosis recorded in hospitalised children at CHBAH.
Discharge summaries were available for 1 148 (78.3%) of 1 466 children admitted during the study period. For completed discharge summaries, 80.1 - 93.3% of patient identifiers and 91.4% of patient outcomes were appropriately completed. HIV exposure was documented in 84.7% of summaries. Anthropometric parameters, including weight and length/height at admission and discharge weight, were appropriately completed in 91.4%, 70.9% and 50.0% of summaries, respectively. The ICD-10 code for children with LRTI was appropriately recorded by medical staff in 338 (67.2%) of 503 cases. ICD‑10 codes and anthropometric parameters, which are important clinical parameters in the paediatric follow-up consultation, were both correctly recorded for only 21.6% of children who required follow-up clinical consultations at CHBAH.
Compared with similar studies, both the rate of completion and the quality of completed discharge summaries were modest in this tertiary academic teaching hospital. As discharge summaries are crucial medical documents, interventions to improve their completeness rate and quality need to be developed.
在南非，医院出院小结被视为病历的重要组成部分，但很少对其质量进行正式评估。在约翰内斯堡的克里斯·哈尼·巴拉格瓦纳特学术医院（CHBAH），从医院档案中很难检索到医疗入院记录（病床记录），而出院小结通常是唯一可随时获取的记录医院入院详细信息的病历。
确定CHBAH普通儿科病房收治儿童的出院小结填写恰当的比例。
对2016年5月1日至7月31日收治儿童的出院小结进行回顾性审查。评估以下人口统计学和临床变量的完整性：患者标识符、医院结局、艾滋病毒感染状况和人体测量状况。对诊断为任何形式下呼吸道感染（LRTI）的儿童（这是CHBAH住院儿童中最常见的诊断），评估其国际疾病和相关健康问题统计分类第十次修订版（ICD-10）编码的记录是否正确。
在研究期间收治的1466名儿童中，有1148名（78.3%）有出院小结。对于已完成的出院小结，80.1%-93.3%的患者标识符和91.4%的患者结局填写恰当。84.7%的小结记录了艾滋病毒暴露情况。人体测量参数，包括入院时的体重和身长/身高以及出院时的体重，在小结中的填写恰当比例分别为91.4%、70.9%和50.0%。在503例LRTI儿童中，医务人员正确记录ICD-10编码的有338例（67.2%）。在CHBAH需要进行后续临床会诊的儿童中，只有21.6%的儿童ICD-10编码和人体测量参数（这是儿科后续会诊中的重要临床参数）均记录正确。
与类似研究相比，这家三级学术教学医院出院小结的完成率和完成质量都一般。由于出院小结是关键的医疗文件，需要制定干预措施来提高其完整率和质量。
