Chris Robey - The Adelaide Clinic, Ramsey Healthcare - A Private Hospital Perspective: Discharge Summaries - Are they Worth the Paper they are Written On?

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Health & Medicine

Published on February 25, 2014

Author: informaoz



Chris Robey, Health Information Manager/Privacy Officer, The Adelaide Clinic, Ramsay Healthcare presented this at the 5th Annual Clinical Documentation, Coding and Analysis Conference. This event is the only case study led conference in Australia looking solely at clinical documentation, coding and analysis.

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Chris Robey Health Information Manager / Privacy Officer Ramsay Healthcare SA

Established in Sydney in 1964 by Paul Ramsay A global hospital group operating over 116 hospitals and day surgery facilities across 4 countries - Australia, France, UK & Indonesia Over 9,000 beds Over 30,000 staff Leading provider of private psychiatric services in Australia & France Listed in the top Global 100 Most Sustainable Corporations in the world

Do the Ramsay Health Care SA patient Discharge Summaries have enough information for General Practitioners for continuum of patient care Process used by Ramsay Healthcare SA for distribution of copies of the Discharge Summary to the GP’s GP Discharge Summary Audit Documentation legibility Future Initiatives

98% of Discharge Summaries at the Adelaide Clinic are hand written 2% are typed by the Psychiatrist Rooms and are sent directly to the GP and other health service providers. Electronic Discharge Summary developed by Ramsay Healthcare IT Paper Discharge Summary due for review in 2014

Medical Record is kept on the ward 24 hrs after discharge. Medical Record is brought down to the Medical Records Department by the ward clerk / AIN Discharge Summary is then photocopied GP details are checked on either Admission Form or through the online Health Provider Registry Summary posted to GP

Incorrect GP details in Meditech Staffing GP details missing on Summary Illegible GP details Incomplete Discharge Summaries Incorrect / missing details on the Health Provider Registry Medical Records going from ward to ECT suite

The audit and survey came about as a result of feedback from our accreditation. The audit was divided into two parts: Discharge Summary Audit and GP survey & response The Audit & survey was conducted over a period 3 months The Audit & Survey was done only for long-stay admissions to the Adelaide Clinic Each copy of the Discharge Summary posted out during the audit period would have a survey for the GP to complete

FACILITY (TAC, Name of FPH, UR Treating Date of KDC) number Psychiatrist discharge Was a dc Date MR summary received requested in MR to go to departm GP or ent other Was dc Was the dc Date dc summary summary summary available in sent out by mailed patient Was the dc Psychiatrist out to Medical completed (typed copy) GP/Other Record in the MR What further follow up was required if dc Time summary not taken to available / not send dc complete summary

Discharge Summaries were sent out anywhere between 1 & 56 days once the Medical Record was received in the department Average over audit period was 8 days Results of audit were summarised by Quality Manager and sent to CEO and the MAC (Medical Advisory Committee) October 2013 Psychiatrist’s on MAC reviewed results and thought the average time of 8 days to send out summaries was incorrect as they completed their summaries on day of discharge. Psychiatrist’s thought Coding was to blame for delay in summaries getting to GP’s

RHC SA Survey - Discharge Summary 2013 8.64 Q3 Info helpful 21.95 Q2 Legible 19.28 Q1 Timely 0.00 10.00 20.00 yes no 30.00 no 40.00 50.00 yes 60.00 Q1 Timely Q2 Legible Q3 Info helpful 80.72 78.05 91.36 19.28 21.95 8.64 70.00 80.00 90.00

 Q1 - Timeliness “written 5/7 not received until 17/7” “but patient came in prior to letter” “ took 2 weeks from date of discharge to arrive”  Q2 – Legibility “very difficult to read” “only just legible” “slight difficulty, preferred typed”  Q3 – Information Helpful “changes to medication routine very useful” “inadequate details regarding risk issues”

“medication changes and follow up plans” “Why patient stayed inpatient that long(? Usually expected) initial management strategy and dc outcome” “info given was good, basically I need a diagnosis and the discharge drugs – everything else is a bonus” “time frame for follow up of patient and earlier arrival of discharge summary” “a little more clinical details” “history of events, ongoing management, progress of patient”

“typed clinical letters with full details” “ put the phone and fax number of the hospital on the Discharge Summary” “consider fax or E-mail Discharge Summary in order to receive it sooner” “add risk assessment” “typed report would be good” “overall good – earlier distribution of Discharge letter – helpful” “E-mail; telehealth”

Review of Discharge Summary format Method of delivery: ?post ?fax ?E-mail Change from Paper to Electronic

“Discharge Summaries – Are they worth the paper they are written on?”

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