QI Story: Enhancing Discharge Summary Documentation at AIC Kijabe Hospital, Kenya

Presented By: Grace Nguni Nthiana, Clinical Officer – BSc. Family Health, HND Quality Assurance Officer, AIC Kijabe hospital

This project focuses on evaluating the impact of regular training on the clinical team’s documentation of discharge summaries in a hospital that transitioned to electronic medical records in 2019. The shift to EMR improved patient tracking but led to challenges, including time constraints and incomplete documentation.

Training was initiated after concerns arose about missing critical information in discharge summaries. The Joint Commission’s mandated components for quality discharge summaries were adopted. Analysis revealed that, before training, only 12% of summaries met the required 5 components. After 7 months of training, over half (52%) had the necessary components, with nearly 80% achieving 4/5 components.

The study highlights the positive impact of regular training on healthcare professionals’ documentation practices and emphasizes the importance of maintaining high standards in documentation for patient care and hospital revenue. The recommendation suggests the establishment of quality departments to reinforce the significance of maintaining documentation standards amidst time constraints in patient care settings.

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