PURPOSE: Patients admitted to the hospital with pleural effusions undergo various diagnostic and therapeutic pleural procedures. An NHS Alliance poll found that 70% of GP's receive late and incomplete discharge summaries, 58% of GPs reported that the patients' care was compromised as a result of this and 39% claimed that it had put patients' safety at risk. Accurate medical documentation is essential for:1. Ensuring patient centred care.2. Appropriate reimbursement.This audit was to ascertain the level of medical documentation in DGH.
METHODS: This was a retrospective analysis of anonymised data extracted from the hospital medical records including discharge summaries (letters to GP) and clinical coding of patients admitted to the hospital with pleural effusions between July 2005 to October 2006.
RESULTS: Overall only 60% of all pleural procedures were documented in the discharge summaries and only 66% were coded by the Coding Department. Pleural procedures were recorded in 91% of patients. Diagnostic pleural tap was the least documented procedure, being recorded in only 59% of patients.
CONCLUSION: 1. A significant number of pleural procedures were not documented on discharge summaries and as a consequence of this were not coded.2. Inaccurate information on patients' management during hospital admission reflects poor medical practice and can compromise further management of the patient and the patients' outcome. 3. Poor documentation of pleural procedures also results in a significant loss of income to the hospital.4. Education to improve medical staff awareness and medical documentation is essential.
CLINICAL IMPLICATIONS: There is poor documentation of pleural procedures, which can compromise patient safety and cause loss of income to Hospital. Medical staff awareness and education to improve this is essential.
DISCLOSURE: Vinod Aiyappan, No Financial Disclosure Information; No Product/Research Disclosure Information