An evaluation of the quality of discharge summaries from the general paediatric wards at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.
The availability of a discharge summary, with adequately recorded information, has demonstrable direct benefit for the patient. A recent study conducted in the USA showed that interventions to improve the discharge summary quality directly contributed to faster recovery rates and lower hospital readmission rates for cardiac failure patients. 
In South Africa (SA), the discharge summary document is of vital importance to patients and healthcare workers (both at the admitting hospital and associated referral clinics or hospitals) because it is often the only detailed record of a hospital admission. Notwithstanding the fact that the Department of Paediatrics at Chris Hani Baragwanath Academic Hospital (CHBAH) is one of the largest paediatric facilities in Africa, paediatric admission files are extremely difficult to retrieve from the CHBAH record archive, as is also the situation in many other clinical departments in SA state hospitals. [8-10]
To determine the quality of discharge summaries that were completed for general paediatric admissions at CHBAH.
A retrospective review of discharge summaries completed for children admitted to the general paediatric wards from 1 May to 31 July 2016 was undertaken. In the Department of Paediatrics at CHBAH, each discharge summary is completed by hand, in triplicate, using a carbon-paper pro forma template; one copy of the summary is filed in the patient-retained outpatient file and the second in the hospital archive, while the third is sent for capture into an electronic database maintained by the Respiratory and Meningeal Pathogens Research Unit (RMPRU). The summaries are most often completed by interns, and occasionally by medical students, medical officers and registrars. The paper-based discharge summary was designed by clinicians to capture clinical information pertinent to this setting.
Through active monitoring of the ward admission registers maintained by the nursing staff, the RMPRU is able to track all admissions to the general paediatric wards. Discharge summaries collected by RMPRU staff are then cross-checked with the ward admission registers, which record the name of the patient and his or her age, gender, hospital number, date of admission, and date of discharge or death. This allows for missing, inaccurate or unfinished summaries to be completed or corrected by the RMPRU staff. Two physicians at the RMPRU also verify the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) against the code written by the doctor on the discharge summary and the preliminary admission diagnosis written in the nursing admission register. This system provides an opportunity to assess whether information is appropriately recorded on the discharge summary form. For missing discharge summaries, the RMPRU staff extract available information from the admission registry, which includes the age of the child, diagnosis at time of admission and outcome of the hospitalisation. This allows for the electronic capture of all admissions to the general paediatric wards at CHBAH.
On discharge summaries completed by the hospital staff, we determined whether information was appropriately completed/ recorded in the following fields: (i) patient identifiers (first name, surname, gender, hospital number, and dates of birth, admission, and discharge or death); (ii) outcome of hospitalisation; (iii) details of doctor completing the summary (name, signature and date of completion of summary); (iv) HIV status (HIV exposure, and CD4+ and viral load results for infected children); (v) anthropometric status (admission weight and length/height, presence of nutritional oedema, and discharge weight); (vi) ICD-10 codes for children diagnosed with any form of lower respiratory tract infection (LRTI) (e.g. bronchopneumonia, bronchiolitis, lobar pneumonia, etc.); (vii) follow-up requirement (at CHBAH and/or other health facility); and (viii) reasons for follow-up at CHBAH. Criteria used to deem a field appropriately completed were defined prior to the analysis. Briefly, for domains requiring alpha characters (for example, first name and surname), fields that were not filled in or were illegible or indecipherable (i.e. not clear enough to be read by at least two of three observers) were regarded as missing or incomplete. For domains requiring numerical characters (such as hospital numbers, dates and anthropometric measurements), fields that were not filled in or were illegible or indecipherable were regarded as missing or incomplete. Hospital numbers were regarded as incomplete if a single digit was missing and anthropometric measurements were regarded as incomplete if not recorded to the first decimal point. For ICD-10 codes, we deemed any code representative of any form of LRTI (generally codes from J09 to J22) to be appropriately recorded if the written diagnosis was compatible with any form of LRTI and verified by RMPRU physicians.
All the study variables, as defined in the data collection sheet, are categorical (or nominal) variables. Frequency distributions were reported for all the study objectives. Potential relationships between categorical variables were analysed using contingency tables (either Fisher's exact test or the [chi square] test).
The study was approved by the Human Research Ethics Committee of the University of the Witwatersrand (ref. no. M160920).
During the 3-month study period, the admission registers showed that 1 466 children were admitted to the general paediatric wards at CHBAH. Of these, 1 148 (78.3%) had a discharge summary available for entry into the database. This indicated that 21.7% of discharge summaries were either not completed or misfiled before capture into the database. We therefore determined whether information was appropriately recorded in 1 148 records (Table 1), i.e. summaries completed solely by the RMPRU staff were not analysed. For patient identifiers and outcomes, 80.0-93.3% and 91.4% of fields, respectively, were appropriately recorded by the doctor completing the discharge summary. It was rare for the doctor to leave the patient name and surname domains blank (0.1%), but indecipherable or illegible handwriting accounted for 8.4% of instances where the name domains were not appropriately recorded.
The HIV exposure of the admitted children was documented for 84.7% of cases, including 58 (5.4%) who were HIV-infected. Among HIV-infected children, 89.7% had CD4+ lymphocyte counts and 87.9% HIV viral load measurements completed. The anthropometric parameters were appropriately documented in 50.0-91.4% of summaries. The admission weight (91.4%) was more appropriately recorded than the admission length/height (70.9%) (p<0.0001) and discharge weight (50.0%) (p<0.0001). The ICD-10 code for children with LRTI was appropriately recorded in 338 of 503 cases (67.2%).
Requirement for follow-up (either at CHBAH or at another health facility) was appropriately completed for 1 065 (92.8%) of the 1 148 summaries. For the 794 children who required follow-up at CHBAH, the reason for follow-up was stated in 721 (90.1%) (Fig. 1). The main reasons for follow-up were clinical assessment (75.8%), evaluation of outstanding laboratory results (9.8%) and repeat anthropometric measurement (usually a check for weight gain) (5.2%).
We further compared the rates of appropriately completed discharge summary fields by month to determine whether discharge summary quality improved as interns spent more time in the Department of Paediatrics; the same group of interns was assessed during the study period. Although there were statistical differences in some parameters, we did not consider these to be of major clinical relevance because the quality of summaries did not consistently improve with time.
The effects of discharge summary quality on follow-up visits
For the 334 children with an LRTI diagnosis and who required further follow-up at CHBAH, we determined whether both their ICD-10 code and anthropometric fields (since these are critically important clinical parameters) were appropriately recorded on the summary. Incomplete or inappropriately recorded discharge weights (n=178, 53.3%) and ICD-10 codes (n=117, 35.0%) were the commonest domains that were poorly recorded. Overall, only 72 (21.6%) of 334 children with LRTI had both ICD-10 codes and anthropometric parameters appropriately completed (Fig. 2).
In the present study, we found that discharge summaries were only completed for approximately four of every five children admitted to the general paediatric wards at a national tertiary academic hospital. This is of concern, because discharge summaries are often the only record of a hospital admission that can be accessed readily. Furthermore, the rate of completed discharge summaries compares unfavourably with settings in Australia and the USA, [11,12] where >99% of discharge summaries are completed. To our knowledge, the completion rate of discharge summaries in SA state hospitals is not known, but the poor rate of retrieval of hospital records (~39% in district hospitals ) and acknowledgement of poor hospital record management systems [9,10] make it likely that missing discharge summaries are an important problem in SA.
Noting that section 10 of the National Health Act No. 61 of 2003  states, in part, that All healthcare providers must supply patients with discharge reports. At the bare minimum these should contain the following information: the health service rendered, the patient's prognosis and the need for follow-up treatment,' we find that the completion rate of discharge summaries and the documentation of important medical information were much lower than desired. Based on findings from a prospective US-based study, which showed that measures to improve the discharge summary quality resulted in lower hospital readmission rates,  we speculate that poorly completed discharge summaries compromise further clinical care and/or result in further unnecessary healthcare visits and/or costs in our setting.
A major limitation of the present study is that we were unable to verify the accuracy of the information in the discharge summary against a 'gold standard' because retrieval of archived hospital records at CHBAH (currently and at the time of the study) is very difficult. Nonetheless, we assessed the quality of the discharge summary because it is often the only readily available record of a hospital admission. We chose parameters such as patient identifiers and ICD-10 codes because the patient identifiers could be verified by checking against the nursing admission register and ICD-10 codes undergo verification at the RMPRU, which address some of the weaknesses of not having the admission notes available. Had we compared the contents of the discharge summary against the actual admission notes, it is likely that the percentage of discharge summaries containing appropriately recorded diagnostic information would be lower.
It is possible that completed discharge summaries were misfiled or lost before reaching the RMPRU database, but we believe that this is highly unlikely--the more probable explanation is that discharge summaries were not completed in the first instance. We speculate that the main reason for the relatively low rate of completion is that discharge summaries require timeous preparation: the intern needs to complete the summary by the time the child leaves the ward.  Factors that aggravate this situation--for example, when the discharge is performed in haste to lessen the pressure on occupied hospital beds (the study period coincided with the period when hospital admission rates were at their highest, and there is a relatively high patient load at CHBAH)--may have contributed to the low completion rates. 
There are several documented methods to improve discharge summary quality: educational training, [15-17] the use of electronically generated discharge summaries,  the provision of incentives,  and having more senior doctors complete the discharge summary.  The feasibility of using these methods to improve discharge summary quality should be assessed, not only for the patient's benefit  but also because good-quality discharge summaries contribute essential information that is used for public health system operations in SA. For example, ICD-10 codes require accurate recording because hospitals will require accurate diagnostic codes when purchasing services from the proposed National Health Authority (as envisaged in the proposed National Health Insurance). 
In SA state hospitals, we propose that improvement of discharge summary quality be prioritised as part of an urgent upgrade of hospital record systems because this is a feasible intervention that is likely to improve clinical care,  health system planning and research output. Consideration should therefore be given to establishing teams in the health facility that are dedicated to controlling the quality of the discharge summary and ensuring that ICD-10 coding is done in a standardised manner to provide more robust data.
In summary, although we cannot extrapolate our results to other institutions, the poor quality of completed discharge summaries is concerning; CHBAH is a central academic hospital, and it is likely that the quality of discharge summaries may be worse in other state hospitals. Discharge summary quality assessments should be carried out regularly, and further studies are needed to assess the effect of interventions to improve discharge summary quality and the impact of good-quality discharge summaries on patient health and health system functions in SA.
Declaration. This publication is a result of the work done by SS for her MMed degree in Paediatrics.
Author contributions. Substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work: SS, FS, SAM, ZD, SGL; drafting the work: SS, SGL; revising the work critically for important intellectual content: FS, SAM, ZD; final approval of the version to be published: SS, FS, SAM, ZD, SGL.
Funding. SAM is funded in part by the Department of Science and Technology/National Research Foundation: South African Research Chair Initiative in Vaccine Preventable Diseases and the Medical Research Council of South Africa. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflicts of interest. None.
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Accepted 16 May 2018.
Corresponding author: S G Lala (email@example.com)
S Singh, (1) MMed (Paediatrics); F Solomon, (2,3) MFamMed; S A Madhi, (2,3) PhD; Z Dangor, (1,2,3) PhD; S G Lala, (1,4) PhD
(1) Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
(2) Medical Research Council Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
(3) Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
(4) Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Table 1. Proportions of parameters that were complete and accurate in paediatric discharge summaries (N=1 148) Domain n (%) Patient identifiers Name 1 050 (91.5) Surname 1 042 (90.8) Gender 1 071 (93.3) Hospital number 962 (83.8) Date of birth 920 (80.1) Date of admission 963 (83.9) Date of discharge 933 (81.3) Discharge outcome 1 049 (91.4) Doctor details Name 1 124 (97.9) Doctor's date 1 085 (94.5) HIV exposure 972 (84.7) Anthropometric parameters Admission weight 1 049 (91.4) Admission length/height 814 (70.9) * Discharge weight 575 (50.0) ([dagger]) Nutritional oedema 1 032 (89.9) LRTI 503 (43.8) Correct ICD-10 for LRTI 338 (67.2) LRTI = lower respiratory tract infection; ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10th revision. * The admission weight (91.4%) was more appropriately recorded than the admission length/height (70.9%) (p<0.0001) and ([dagger]) discharge weight (50.0%) (p<0.0001). Fig. 1. Reasons for paediatric follow-up at CHBAH following hospital discharge. (CHBAH = Chris Hani Baragwanath Academic Hospital.) Clinical assessment (75.8%) n=602 Weight check (3.4%) n=27 To check outstanding laboratory results (9.8%) n=78 Weight check + outstanding lab results (1.8%) n=14 Reason for follow-up unknown (9.2%) n=73 Note: Table made from pie chart. Fig. 2. Percentages of discharge summaries with accurately recorded ICD-10 codes and anthropometric parameters completed for children with LRTI. (LRTI = lower respiratory tract infection; ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10th revision; adm = admission; wt = weight; lt = length; ht = height; disch = discharge; CHBAH = Chris Hani Baragwanath Academic Hospital.) Children with LRTI requiring follow-up at CHBAH, n Eligible for assessment: 100% Correct ICD-10 coding: 65.0% Correct ICD-10 coding + adm weight: 61.4% Correct ICD-10 coding + adm weight + adm lt/ht: 47.3% Correct ICD-10 codino +adm weight + adm lt/ht + disch wt: 21.6% Note: Table made from bar graph.
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|Author:||Singh, S.; Solomon, F.; Madhi, S.A.; Dangor, Z.; Lala, S.G.|
|Publication:||SAMJ South African Medical Journal|
|Date:||Nov 1, 2018|
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