CLINICAL AUDIT

Secular trends in the medical discharge summary in an acute medical hospital

K M Chow, C C Szeto

Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China

Correspondence to:
Correspondence to:
Dr K M Chow
Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong; Chow_Kai_Ming{at}alumni.cuhk.net

Background: Although recent research has reported an evolution in the level of medical care, little is known about secular trends in the medical discharge summary.

Methods: The audit evaluated the evolution of discharge summary abstract over a decade in an acute medicine hospital among three successive periods of 1994, 2000, and 2005.

Results: Of the 140 random samples of discharge summaries, significant between-cohort difference existed in the logarithm transformed length of discharge summary; the median length of discharge summary increased from 11 lines in 1994 to 26 lines in 2005 (p<0.001 corrected for multiple comparison). The closest univariate associations of discharge summary length were positively with the year of hospitalisation, length of stay, length of wordings about discharge plan and duplication of previous discharge summary, and negatively with clinical or planned admission (all p<0.01). In a multiple linear regression analysis, the year of patient admission correlated significantly with the length of discharge summary (p<0.001).

Conclusions: Over the 10 year study period, significant secular trends were seen in the discharge summary length and discharge plan documentation. The causes and implications for these trends deserve further investigation.

Keywords: discharge summary; hospital notes; audit; medical record; quality improvement

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