The Quality of Discharge Summaries at a Tertially Level Hospital in Tanzania

Background: A discharge summary is a document prepared by a doctor at the end of the patient's hospitalization with an intention of transferring patient’s information from in-patient to out-patient settings and between hospital admissions. The World Health Organization recommends a good summary to include patient identification, reasons for admission, examinations and findings, treatment while in the hospital and proposed follow up plan.Objectives: This study aimed at assessing the quality of discharge summaries based on the completeness of documentation of their different sections.Materials and Methods: A descriptive cross-sectional study conducted at Muhimbili Orthopedic Institute (MOI) to assess discharge summaries of patients with femoral shaft fracture treated by intramedullary nailing between July and December 2021.Results: One hundred twenty-five (125) discharge summaries were included, all of which were hand written. None of them had complete documentation in all the five domains as recommended by the WHO. In the section of patient identification, sex was the most documented parameter (98.4%) while the Patients’ names and date of birth were partially documented in 99.2% and 97.6% of all discharge summaries respectively and telephone numbers were not documented at all in 98.4% of DS. The surgery performed was the most documented patient’s hospital stay parameter (56%) whereas the name of the discharging doctor was partially filled in 96.8% of DS. None of the DS documented post-operative complications. The section on the condition of the patient at discharge was the least filled of all four sections, where the vital signs were completely written in only 5.6% of all DS while 93.6% and 84% of them did not report on physical examination and history respectively. In the section of post discharge instruction majority of them reported on post discharge medications (95.2%), while 90.4% had incomplete information on date for the next visit, post discharge wound care and modality of ambulation were not written in 59.2% and 56% of DS respectively.Conclusions: Most of the discharge summaries were partially documented. Efforts should be targeted in emphasizing appropriate documentation to avoid the adversities that may result from lack of sufficient information.