A Comparison of Methods of Producing a Discharge Summary: handwritten vs. electronic documentation

Background: It is a compulsory requirement that a hospital produces a discharge summary. This is often the only documentation a GP receives in relation to a recent admission. Traditionally the discharge summary is hand-written and commonly known as the TTA (‘to take away’). Recently the EDS (electronic discharge summary) has been introduced. This audit provides a comparison of the TTA and EDS. Methods: A random sample of 50 TTAs and 50 EDSs were selected from one ward over a two-month period. Completion rates for criteria of the discharge summary were analysed. Results: The EDS is a superior form of discharge summary, significantly for documenting diagnosis, co-morbidities, investigations, drug history and instructions for the GP. Conclusions: Junior doctors should be more aware of the importance of the discharge summary; therefore they should provide clear, complete and concise information. In order to ensure EDSs are completed correctly training on using the computer programme should be more thorough. Documenting comorbidities has implications on clinical coding. Other healthcare professionals should contribute to the discharge summary.