Background and objective: According to the Swedish board of health and welfare a patient should receive a discharge letter containing a medication report including information about all medication changes during the admission, and the reason behind them, at discharge. Hospital readmissions have been shown to correlate to poor compliance and mistakes following a lack of information regarding medication changes. This study aimed to improve a recently developed checklist (KU1) and use the new version (KU2) to measure the completeness of discharge documentation. This study was part of ongoing quality improvement projects at the geriatric- and internal medicine clinics.
Study design and setting: This was a retrospective cross-sectional study where data from electronic medical records was reviewed. Patients admitted to two wards at Uppsala University hospital, 30A and 30E, in October 2021 aged 50 years or older and with at least one lasting medication change during the stay were eligible for inclusion.
Method: The already existing checklist KU1 was updated along with an updated standard operating procedure (SOP). The new checklist, KU2, was used in the data collection to review and assess the completeness of patient journals with a score of 7 considered to be a complete discharge.
Results: A total of 80 patient journals (40 from each ward) were reviewed and assessed using the updated checklist, KU2. Across both wards, a total of 19 (23,8%) patient journals scored a perfect 7. This corresponded to 12 (30%) and 7 (17,5%) for 30A and 30E respectively. The most common criteria not being fulfilled in the checklist, was for both wards to miss mentioning at least one relevant change in the discharge summary.
Conclusion: Most discharge documents reviewed in this study did not meet the requirements stated by Swedish law. There is a need for internal quality improvement initiatives as well as further studies in the field.
2023. , s. 31