Upgrading of hospital discharge summary software to optimise covid-19 documentation and safeguard infection prevention in the community

2021 
Aims: Early review of 50 discharge summaries at Royal Shrewsbury Hospital (SATH) in April 2020 revealed only 27% documented the patient’s in-hospital COVID-19 test result and 2% outlined any recommended self-isolation advice following hospital discharge. This had potential adverse implications for community infection control as well as medico-legal sequalae for the Trust were the discharged patient to spread COVID-19 to other cohabitants. The urology team worked with SATH IT to amend the existing discharge summary software, to add two tabs to make COVID-19 test result and self-isolation documentation mandatory for successful sign-off. The aim of this quality improvement project was to evaluate the impact of updating the discharge summary software on documentation accuracy related to COVID-19 on discharge paperwork. Method: Following the implementation of the modified software, 50 consecutive discharge summaries for patients admitted under the urology team starting 1st October 2020 were retrospectively reviewed for documentation of COVID-19 result and self-isolation advice. Results: 90% of discharge summaries included COVID-19 test result and 100% included self-isolation advice for the patient, or alternatively confirmed that no self-isolation was required. Conclusions: This simple modification of an existing IT system greatly improved compliance with COVID-19 discharge summary documentation. We propose all hospitals consider adopting similar measures in the interest of infection prevention, public safety and potential medico-legal sequalae. © 2021, JMN Medical Education Ltd. All rights reserved.
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