The quality of dermatology consultation documentation in discharge summaries: a retrospective analysis

Abstract

Introduction: Good quality documentation of dermatology consults in discharge summaries allows diagnostic and therapeutic plans to be communicated to other health professionals and ensures that appropriate governmental funds are provided to dermatology departments. Methods: A retrospective analysis was performed of all dermatology consults seen in 2013 at a public tertiary hospital in Sydney, Australia. Results: Two hundred nineteen discharge summaries related to inpatient dermatology consultations were analysed; 80.6% of dermatology consults, 72.2% of skin biopsies, and 57.6% of diagnoses were duly included in the discharge summaries; 82.5% of the discharge summaries were completed before the discharge. The accuracy rate of diagnosis documentation was 54.5% and was correlated with clear dermatology team documentation, the use of a problems list, infectious skin diseases and junior medical staff authorship. Conclusion: This study highlights the need for improvement in dermatology consult documentation in discharge summaries. It suggests the use of a problems list in discharge summaries, clarity in dermatology teams’ documentations, and postdischarge follow-up. Key words: medical records, discharge summary, quality assurance, public health, consultation