759 Electronic Discharge Summary Audit

نویسندگان

چکیده

Abstract Aim Electronic discharge summaries (EDS) in General Surgery were found to be lacking adequate clinical information. The Professional Records Standards Body (PRSB) released guidance, endorsed by NICE, with the information required an electronic summary. aim of study was monitor and record how many EDS’s have been completed all relevant/required sections completed. Method A retrospective analysis EDS 50 patients admitted under general surgery at Worcestershire Royal Hospital conducted. Yes, No or N/A marked against 13 categories based on PRSB guidelines. 4 cycles carried out between 2020 2022. After cycle 1, a poster introduced outlining criteria for (Figure 1). printed version placed doctor’s office. 2, feedback collected from junior doctors who suggested teaching session write summaries. delivered prior 3 4. Results overall level compliance each as follows-Cycle 1- 8% complianceCycle 2- 22% 3- 34% 4- 69% Conclusions proved effective improving compliance.It there poor completing comorbidities section EDS. Acknowledging helped provide useful sessions so we will continue regular sessions. Continue annual audit EDS' increase compliance.

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ژورنال

عنوان ژورنال: British Journal of Surgery

سال: 2023

ISSN: ['1365-2168', '0007-1323']

DOI: https://doi.org/10.1093/bjs/znad258.523