J O Jansen1, I C Grant. 1. Accident and Emergency Department, Derriford Hospital, Plymouth, UK.
Abstract
OBJECTIVES: Accident and emergency departments see large numbers of patients, and computerised administration systems are a useful tool for producing discharge communication. The purpose of this study was to determine the quality of such correspondence. METHODS: Retrospective review of 300 discharge letters and case notes. RESULTS: 29% of all computer generated discharge information was incomplete or misleading. Twenty five per cent of all correspondence was lacking or unacceptable overall. The principal reasons for substandard correspondence were inaccurate coding of diagnoses and procedures, and failure to include specific information relevant to patients' follow up. CONCLUSIONS: Computer generated discharge communication is often deficient. Staff using such systems should be made aware of the importance of accurate coding, and use added explanatory text to clarify diagnoses, management, and follow up as required.
OBJECTIVES: Accident and emergency departments see large numbers of patients, and computerised administration systems are a useful tool for producing discharge communication. The purpose of this study was to determine the quality of such correspondence. METHODS: Retrospective review of 300 discharge letters and case notes. RESULTS: 29% of all computer generated discharge information was incomplete or misleading. Twenty five per cent of all correspondence was lacking or unacceptable overall. The principal reasons for substandard correspondence were inaccurate coding of diagnoses and procedures, and failure to include specific information relevant to patients' follow up. CONCLUSIONS: Computer generated discharge communication is often deficient. Staff using such systems should be made aware of the importance of accurate coding, and use added explanatory text to clarify diagnoses, management, and follow up as required.
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