article · The Egyptian Orthopaedic Journal
Discharge summaries transfer vital patient details from in-patient hospital care to outpatient environments and future visits. An evaluation of 125 handwritten discharge summaries for patients treated for femoral shaft fractures at Muhimbili Orthopaedic Institute revealed that none fulfilled all five documentation domains recommended by the World Health Organization. Essential patient identification details, such as full names, dates of birth, and telephone contacts, were frequently incomplete or missing. Clinical details also showed substantial gaps, with no records documenting postoperative complications, and vital signs recorded completely in only 5.6 percent of cases. Physical examinations and patient histories were missing in over 80 percent of documents. Post-discharge medication was documented in 95.2 percent of summaries, but instructions regarding follow-up visits, wound care, and ambulation remained mostly incomplete or unrecorded. The findings highlight significant documentation deficiencies that need targeted institutional interventions.
When patients leave the hospital, complete medical records ensure that continuing healthcare providers understand previous treatments and upcoming care plans. Incomplete handwritten records, as highlighted here, can leave out crucial details like postoperative issues or wound care instructions. Addressing these documentation gaps is essential for preventing medical errors and safeguarding patient recovery during transition from hospital to home.
The abstract does not indicate an application pathway or discuss commercial products. However, the findings highlight a clear operational deficit in manual clinical paperwork that could inform the adoption or design of electronic medical record and standardised documentation tools for tertiary hospitals.
AI-generated from the published abstract. Always read the original work before citing.
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.
This page summarises published work. The authoritative version sits with the publisher.
DOI: 10.21608/eoj.2025.467112
Is something wrong with this record? Report it or request removal.
Discussion
Have you built on this work, tried to replicate it, or seen it applied in practice? Share what you know. Verified researchers and MARATTO™ domain experts can open a discussion, and any member can reply. Contributions are reviewed before they appear.
No discussion yet. Open the first thread.
New to MARATTO™? Create a free account.
