[Extensive normalization of the surgical discharge report. An efficient quality alternative]

Abstract

Objective: To improve the quality of the clinical information documents received by surgical patients when discharged from the Hospital.

Material and methods: A preliminary analysis of the quality of the surgical discharge form (SDF) included information regarding the time of issue (provisional vs. definitive), legibility/standardization (typewritten, hand-written with or without a standardised format), technical quality (complete vs. incomplete) and retrievability (electronically storage or not). This analysis showed that 39% of the forms were either provisional, incomplete or were standardised formats (59%) or hand-written as a simple medical note (41%). We have redesigned the methodology for filling in the SDF and their storage using the resources available in our Hospital. We designated a common surgical secretary to fill in all the SDF and designed 81 standard formats in Word for all the surgical procedures. A consensus protocol was also developed with the different surgical departments for the completion, distribution and monitoring of the SDF. Finally we established a Windows-based computerised system for centralized storage/retrieval of the discharge forms that could be easily accessed by internet.

Results: All the SDF are standardised and electronically stored. The patient receives a typewritten form at the time of discharge. The dates for the first surgical or outpatient review are included in 98% of the SDF from hospitalised patients and in 100% of the SDF from major ambulatory surgery patients. We did not reach the expected outcome for minor surgical procedures.

Conclusions: The extensive standardisation of the SDF, together with the new methods for completing them, has shown to be an efficient measure to maximise the quality of the clinical information given to the patient and to minimise the waiting time from the physician confirming discharge to the patient eventually leaving the hospital.