Abstract Number: 229

Recording of dermatology consults in dischargesummaries: an analysis of 218 consults

C.Y. Zhao , R.Y. Ang , R. George , D.F. Murrell

Meeting: 2015 Dermcoll

Session Information

Date: -

Session Title: Poster Presentations

Session Time: -

Introduction: Discharge summary (DCS) is a critical document.
Accurate documentation of dermatology consults in
the DCS helps communication with primary care, and to
capture the care provided to the patient, in order to facilitate
Activity-based Funding.

Method: We retrospectively audited all dermatology consults
seen at St George Hospital throughout JanuaryDecember
2013 and the associated DCS by the nondermatology
teams.

Results: Altogether, 218 dermatology consults/admissions
were analysed. Of these, 206(94.5%) had a DCS and
188(86.2%) had a punctual DCS (completed before/on the
discharge date). Only 143 of 218(65.6%) dermatology consults
and 32 of 46(69.6%) skin biopsies were documented on
discharge summaries.
Of the 234 dermatological diagnoses made, 121(51.7%)
were accurately documented, 51(21.8%) undocumented,
45(19.2%) wrongly documented, 11 (4.7%) without DCS
and 6(2.5%) had spelling errors. Out of the 51 undocumented
diagnoses the commonest groups were dermatitis
(N = 16,31.3%) and infections(N = 16,31.3%).
Dermatology clearly documented 205 of 218(94.0%) consults;
the rest were abbreviated (N = 4,1.8%) or had unclear
explanation of biopsy results (N = 9,4.1%).
Using an issues list in the DCS gave increased odds of
documenting the dermatology consult(OR 1.27,CI 0.70–
2.30). Specialty-wise, paediatrics had the highest percentage
of consult documentation(8 of 9,88.9%), followed by
critical care(12 of 14,85.7%), surgical(25 of 35,71.4%),
medical(95 of 140,67.9%) and psychiatry(3 of 8,37.5%).

Discussion: With concern, we found high rates of undocumented
or incorrectly documented consults in hospital DCS.
Strategies to improve include the use of an issues list, avoidance
of diagnoses abbreviations, clearer explanation of
biopsy results, as well as the dermatological education of
other specialties, especially psychiatry and, surprisingly,
medical specialties.