• N C Oguego, O Okoye, A Aghaji, F C Maduka-Okafor, O I Okoye, and I R Ezegwui.
• Department of Ophthalmology, University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria.
• Niger J Clin Pract. 2018 Jul 1; 21 (7): 901-906.

BackgroundDischarge summaries are important components of hospital-care transitions in ensuring continuity of care.AimWe assessed the adequacy and accuracy of discharge summaries written by junior doctors.MethodsAn instrument, adapted largely from the current hospital discharge summary template and recommendations regarding content from the Joint Commission International, was used to study 420 discharge summaries written in 2012 from the ophthalmology service of a Rural Teaching Hospital in Nigeria. The simple descriptive analysis was done with Statistical Package for the Social Science version 17.ResultsCompleteness of entries was relatively high in many traditional areas (biodata of patient, admission/discharge dates, name of supervising consultant, principal diagnosis, surgical procedures done, follow-up instructions, and condition on discharge) of the summaries. The portion of the paper-based template titled "summary" of the admission was most problematic; with information on medication changes and result of tests missing in 368/420 (87.6%) and 334/420 (79.5%), respectively.ConclusionEducational intervention for doctors in training with the provision of oversight and feedback by their supervisors is required. Standardized discharge summary templates recognizing the peculiarities of specialized patient groups are recommended. Transition to electronic discharge summary system is imperative.

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