audit discharge summary
Post on 03-Mar-2015
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ObjectiveTo assess the entry of Opthalmologist’s findings in the
discharge summaryTo assess the entry of Opthalmologist’s findings in the
discharge summary
Criteria
•All findings need to be included in the discharge summary
Data Collection
•Obtain the list of patients seen by Dr. Devdutt Thomas, compare the case sheets with the discharge summary
Audit - Data Collection
41 patients seen by Dr. Devdutt Thomas were identified ( from office - accounts)
Audit - Data Collection
28 case sheets could be obtained
All of them were confirmed to have been seen by Dr. Devdutt Thomas during their stay in the hospital in the month of Jan & Feb 2011
No Diagnosis Entry Opthal finding
1 Head Injury / Facial injury - lacerations
- Normal
2 Facial Lacerations / Scaphoid # - Normal
3 TKR - Retinal atrophy of Macula
4 Head Injury - Normal
5 DNS, Post traumatic facial deformity
Yes Nasolacrimal duct obstruction
6 TKR - Refractory error
7 Back ache Yes Papilloedema
8 # Mandible / Zygoma - Normal
No Diagnosis Entry Opthal Finding
9 Polytrauma - Normal
10 Head injury - Temporal bone # - Normal
11 Head injury, Loss of vision left eye Yes Globe rupture
12 Facial laceration Yes Keratitis
13 Head injury - Frontal bone # - Normal
14 Facial lacerations, Ulna # - Normal
15 Facial lacerations - Normal
16 Head injury Yes Macular Haemmorrhage
17 Head injury - Normal
No Diagnosis Entry Opthal Finding
18 Head Injury - Diabetic Retinopathy
19 Head injury, Facial lacerations Yes Choroidal tear
20 # Zygoma - Normal
21 Venous malformation & varicosities - lower limbs
- Old traumatic lens dislocation
22 Head Injury, Patella # - Normal
23 Bilateral ZMC #s - Normal
24 Head Injury, Facial lacerations - Normal
25 Frontal bone, Femur, Patella #s - Normal
26 Head Injury, Facial lacerations - Normal
27 Trochanteric # - Normal
28 Head Injury - Normal
Results
6 patients had entries in the discharge summary while the rest did not.
All of these six had associated positive eye findings
Results
22 discharge summaries did not have the Opthalmologist’s findings in the discharge summary
19 had normal opthal findings
The other 3 were patients who requested for opthal consult as they were in the hospital( Refractory error, diabetic retinopathy )
Data Analysis - Inference
All trauma patients with associated eye injuries (positive finding by the Opthalmologist) have had their findings included in the discharge summary
Opthal examination reporting as normal were not being included in the discharge summary
Opthal findings of patients who requested for consultation( non trauma patients) were not always included in the discharge summary
•Check the results
•If meeting the criteria - fine, if not decide on means of implementing the changes to achieve the agreed criteria
•Implement the changes
•Reaudit later to see if they meet the originally agred criteria
Recommendations
Separate sheet for visiting consultants so that the findings can be typed
To get a brief summary of the findings from Dr. Devdutt Thomas to be included in the discharge summary
Instruct all staff nurses and typists to ensure the findings are included
The audit cycleProblem or objective
identified
Criteria agreed and standards
set
Data Collected (Audit)
Identify areas for improvement
Make necessary changes
Reaudit
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