Endoscopy 2004; 36 - 43
DOI: 10.1055/s-2004-834531

Significant Difference in the Handwritten and Dictated Discharge Notes – Outcome of an Audit on Medical Case Records in a Scottish Private Hospital

D Debnath 1, M Hutcheson 1, JK Hussey 1
  • 1Albyn Hospital, Aberdeen, UK; Department of Surgery, University of Aberdeen, Aberdeen, UK and Department of Radiology, University of Aberdeen, Aberdeen, UK

Aim: A comprehensive discharge letter is crucial in liaising with various healthcare personnel. However little is known about the choice of the discharge certificate, more so in the private healthcare. We aimed to assess any difference in the way the discharge letters were recorded by the consultant gastroenterologists and general surgeons in a Scottish private hospital.

Methods: A 12% of all admissions that took place at Albyn Hospital, Aberdeen, between January 2003 and March 2004 were audited. Notes were selected randomly by the computer. The discharge letters were scored to determine the quality of content (1 to 7) and classified as- i)absent ii)handwritten (by using a custom made discharge form) iii)dictated (typewritten) and iv)'combined' handwritten and dictated.

Results: 194 valid notes were audited. The mean discharge score was 5.80±1SE 0.15. Discharge letters were absent in 17 cases. The mean score of dictated discharges (5.41±1SE 0.15) was significantly lower than 'combined' (6.68±1SE 0.12) and handwritten (6.76±1SE 0.06) letters [Oneway Anova; p<0.000001]. Individual results were similar amongst gastroenterologists and surgeons.

Conclusions: The quality of custom made discharge letters, even though handwritten, was significantly better than the personal dictated letters. This should be taken into account while addressing the clinical governance of a healthcare setup.