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Quality and extent of adherence on internal medicine discharge letters in a regional hospital in South Africa to prescribed guidelines. A retrospective audit
Background: Hospital discharge letters are an essential part of good patient record keeping that ensures transmission of the healthcare information of a patient from the hospital of admission to the primary care practitioner. These letters were traditionally handwritten, but the medical ward in Vict...
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| Format: | Thesis |
| Language: | English |
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Department of Public Health and Family Medicine
2020
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| _version_ | 1867613230310883328 |
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| access_status_str | Open Access |
| author | Nya, Anthony |
| author2 | Ras, Tasleem |
| author_browse | Nya, Anthony Ras, Tasleem |
| author_facet | Ras, Tasleem Nya, Anthony |
| author_sort | Nya, Anthony |
| collection | Thesis |
| description | Background: Hospital discharge letters are an essential part of good patient record keeping that ensures transmission of the healthcare information of a patient from the hospital of admission to the primary care practitioner. These letters were traditionally handwritten, but the medical ward in Victoria hospital Wynberg in adapting to current progress in clinical record keeping has transited from paper to the use of electronic discharge letters. Objectives: To audit the structure and contents of the electronic discharge summaries and find out to what extent they meet universally accepted criteria. Methodology: A retrospective clinical record audit of 60 patient records was conducted, spanning a period of 12 months (January-December) of 2018. Sequential sampling was used to select five folders from each months’ discharge records, making a total study sample of 60 patient records. A checklist of prescribed criteria was developed and used to collect data which was analysed descriptively. Ethical approval was obtained from University of Cape Towns’(UCT) Human Research Ethics Committee (HREC) and the Western Cape Government Provincial Research Committee. Electronic discharge letters compiled in the period 1 January- 31 December 2018 with corresponding folders found properly indexed in the medical records department were included in the sample, while discharge letters where the folders could not be found were excluded, as were the folders of patients who died during the hospital admission. Results: Nearly all clinical records contained biodata (100%), contact details (93%) and clinical details (93%). Only two-thirds of the folders contained information on other diagnoses(67%) and investigations matched clinical issues 63%.). The least compliant category was medication changes(53%), with just under half the folders containing this information. Conclusion: This study found that clinical records met 67% of the standards that define clinical and medico-legal compliance in the internal medicine ward in Victoria Hospital Wynberg. Several areas for future intervention were identified. A useful audit tool was also developed for ongoing quality improvement cycle. |
| format | Thesis |
| id | oai:open.uct.ac.za:11427/31798 |
| institution | University of Cape Town (South Africa) |
| language | eng |
| last_indexed | 2026-06-10T12:32:50.328Z |
| license_str | Not specified — see source repository |
| provenance_str_mv | Harvested via OAI-PMH from UCTD — University of Cape Town Open Access Repository |
| publishDate | 2020 |
| publishDateRange | 2020 |
| publishDateSort | 2020 |
| publisher | Department of Public Health and Family Medicine |
| publisherStr | Department of Public Health and Family Medicine |
| record_format | dspace |
| source_str | UCTD — University of Cape Town Open Access Repository |
| spelling | oai:open.uct.ac.za:11427/31798 Quality and extent of adherence on internal medicine discharge letters in a regional hospital in South Africa to prescribed guidelines. A retrospective audit Nya, Anthony Ras, Tasleem Cupido, Clint family medicine Background: Hospital discharge letters are an essential part of good patient record keeping that ensures transmission of the healthcare information of a patient from the hospital of admission to the primary care practitioner. These letters were traditionally handwritten, but the medical ward in Victoria hospital Wynberg in adapting to current progress in clinical record keeping has transited from paper to the use of electronic discharge letters. Objectives: To audit the structure and contents of the electronic discharge summaries and find out to what extent they meet universally accepted criteria. Methodology: A retrospective clinical record audit of 60 patient records was conducted, spanning a period of 12 months (January-December) of 2018. Sequential sampling was used to select five folders from each months’ discharge records, making a total study sample of 60 patient records. A checklist of prescribed criteria was developed and used to collect data which was analysed descriptively. Ethical approval was obtained from University of Cape Towns’(UCT) Human Research Ethics Committee (HREC) and the Western Cape Government Provincial Research Committee. Electronic discharge letters compiled in the period 1 January- 31 December 2018 with corresponding folders found properly indexed in the medical records department were included in the sample, while discharge letters where the folders could not be found were excluded, as were the folders of patients who died during the hospital admission. Results: Nearly all clinical records contained biodata (100%), contact details (93%) and clinical details (93%). Only two-thirds of the folders contained information on other diagnoses(67%) and investigations matched clinical issues 63%.). The least compliant category was medication changes(53%), with just under half the folders containing this information. Conclusion: This study found that clinical records met 67% of the standards that define clinical and medico-legal compliance in the internal medicine ward in Victoria Hospital Wynberg. Several areas for future intervention were identified. A useful audit tool was also developed for ongoing quality improvement cycle. 2020-05-06T10:26:27Z 2020-05-06T10:26:27Z 2019 2020-04-29T09:29:25Z Master Thesis Masters MMed https://hdl.handle.net/11427/31798 eng application/pdf Department of Public Health and Family Medicine Faculty of Health Sciences |
| spellingShingle | family medicine Nya, Anthony Quality and extent of adherence on internal medicine discharge letters in a regional hospital in South Africa to prescribed guidelines. A retrospective audit |
| thesis_degree_str | Master's |
| title | Quality and extent of adherence on internal medicine discharge letters in a regional hospital in South Africa to prescribed guidelines. A retrospective audit |
| title_full | Quality and extent of adherence on internal medicine discharge letters in a regional hospital in South Africa to prescribed guidelines. A retrospective audit |
| title_fullStr | Quality and extent of adherence on internal medicine discharge letters in a regional hospital in South Africa to prescribed guidelines. A retrospective audit |
| title_full_unstemmed | Quality and extent of adherence on internal medicine discharge letters in a regional hospital in South Africa to prescribed guidelines. A retrospective audit |
| title_short | Quality and extent of adherence on internal medicine discharge letters in a regional hospital in South Africa to prescribed guidelines. A retrospective audit |
| title_sort | quality and extent of adherence on internal medicine discharge letters in a regional hospital in south africa to prescribed guidelines a retrospective audit |
| topic | family medicine |
| url | https://hdl.handle.net/11427/31798 |
| work_keys_str_mv | AT nyaanthony qualityandextentofadherenceoninternalmedicinedischargelettersinaregionalhospitalinsouthafricatoprescribedguidelinesaretrospectiveaudit |