Assessment of quality of handwritten discharge tickets of breast cancer patients: the gaps are wide and need remedy.

摘要

BACKGROUND: Discharge tickets (DTs) convey important details related to hospitalization period and follow-up instructions. Therefore, quality of DTs may have significant bearing on subsequent patient care. AIMS, SETTING AND DESIGN: Aim of this retrospective study was to assess quality of handwritten DTs of breast cancer patients admitted at this institution. METHODS AND MATERIAL: DTs of 736 breast cancer patients were evaluated on six predetermined quality parameters by verifying entries from their respective case sheets drawn from the medical record department of this institution. These parameters included sections of discharge tickets dealing with central registration (CR) number, tumor stage, in-hospital treatment details, instructions for subsequent treatment and instructions regarding surgical wound care were evaluated for accuracy and clarity. General legibility was also assessed. The audit was done by the author. RESULTS: Almost all DTs were found to be legible and accurate for CR number. In-hospital treatment details were entered accurately in 98%. Tumor stage was correctly indicated in 57.5%. Follow-up and wound-care instructions were written clearly in 76.5% and 53.9% DTs, respectively. CONCLUSIONS: Handwritten DTs of breast cancer patients at this institution were satisfactory for three, but deficient for three other important quality parameters. These findings suggest that there is an acute need to review practice of preparing handwritten DTs in order to provide good quality of subsequent care.