Upgrading of hospital discharge summary software to optimise COVID-19 documentation and safeguard infection prevention in the community (2021)

Type of publication:
Journal article

*Donati-Bourne J.; *Lo N.; *Selvan M.; *O'dair J.; Mohamed W.; Kasmani Z.

British Journal of Medical Practitioners; Jul 2021; vol. 14 (no. 1)

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(s): 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.
Result(s): 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.
Conclusion(s): 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.

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