Background: The clinical discharge summary remains a critical, but often poorly implemented tool in communication with primary care. An area of concern is the documentation of medication lists and appropriate follow up of medication changes.
Aims: To assesses the accuracy of documentation of medication changes and expectations with regard to follow up from an acute assessment unit (AAU) of a tertiary metropolitan hospital.
Methods: All patients who were admitted and discharged directly from the unit during the month of June 2013 were audited. For all admissions, discharge summaries were audited for medication errors and for the appropriate documentation of indications and follow up for prescribed medications. All medications prescribed on discharge were collated using the World Health Organization Anatomical, Therapeutic and Chemical (ATC) classification.
Results: In total, 219 admissions were analysed. There were 204 out of 219 (93.1%) discharge summaries that had an accurate medication list. Of 219 (74%) patients, 163 had at least one change to their medications during admission. Of 163 discharge summaries, 82 (50%) contained information regarding their indication and outpatient management. The most commonly prescribed classes along with the rates of indication and follow up documentation were anti-infectives (62%), gastrointestinal (51%), cardiovascular (50%) and central nervous system (44%).
Conclusion: Although there were fewer documentation errors in discharge summaries than previously described in the literature, concerns regarding the documentation of medication indication and follow up remain.
Keywords: aftercare; communication; continuity of patient care; discharge summary; patient discharge; quality of healthcare.
© 2014 The Authors; Internal Medicine Journal © 2014 Royal Australasian College of Physicians.