ObjectiveTo assess the entry of Opthalmologist’s findings in the

discharge summaryTo assess the entry of Opthalmologist’s findings in the

discharge summary

Criteria

•All findings need to be included in the discharge summary

Data Collection

•Obtain the list of patients seen by Dr. Devdutt Thomas, compare the case sheets with the discharge summary

Audit - Data Collection

41 patients seen by Dr. Devdutt Thomas were identified ( from office - accounts)

Audit - Data Collection

28 case sheets could be obtained

All of them were confirmed to have been seen by Dr. Devdutt Thomas during their stay in the hospital in the month of Jan & Feb 2011

No Diagnosis Entry Opthal finding

1 Head Injury / Facial injury - lacerations

- Normal

2 Facial Lacerations / Scaphoid # - Normal

3 TKR - Retinal atrophy of Macula

4 Head Injury - Normal

5 DNS, Post traumatic facial deformity

Yes Nasolacrimal duct obstruction

6 TKR - Refractory error

7 Back ache Yes Papilloedema

8 # Mandible / Zygoma - Normal

No Diagnosis Entry Opthal Finding

9 Polytrauma - Normal

10 Head injury - Temporal bone # - Normal

11 Head injury, Loss of vision left eye Yes Globe rupture

12 Facial laceration Yes Keratitis

13 Head injury - Frontal bone # - Normal

14 Facial lacerations, Ulna # - Normal

15 Facial lacerations - Normal

16 Head injury Yes Macular Haemmorrhage

17 Head injury - Normal

No Diagnosis Entry Opthal Finding

18 Head Injury - Diabetic Retinopathy

19 Head injury, Facial lacerations Yes Choroidal tear

20 # Zygoma - Normal

21 Venous malformation & varicosities - lower limbs

- Old traumatic lens dislocation

22 Head Injury, Patella # - Normal

23 Bilateral ZMC #s - Normal

24 Head Injury, Facial lacerations - Normal

25 Frontal bone, Femur, Patella #s - Normal

26 Head Injury, Facial lacerations - Normal

27 Trochanteric # - Normal

28 Head Injury - Normal

Results

6 patients had entries in the discharge summary while the rest did not.

All of these six had associated positive eye findings

Results

22 discharge summaries did not have the Opthalmologist’s findings in the discharge summary

19 had normal opthal findings

The other 3 were patients who requested for opthal consult as they were in the hospital( Refractory error, diabetic retinopathy )

Data Analysis - Inference

All trauma patients with associated eye injuries (positive finding by the Opthalmologist) have had their findings included in the discharge summary

Opthal examination reporting as normal were not being included in the discharge summary

Opthal findings of patients who requested for consultation( non trauma patients) were not always included in the discharge summary

•Check the results

•If meeting the criteria - fine, if not decide on means of implementing the changes to achieve the agreed criteria

•Implement the changes

•Reaudit later to see if they meet the originally agred criteria

Recommendations

Separate sheet for visiting consultants so that the findings can be typed

To get a brief summary of the findings from Dr. Devdutt Thomas to be included in the discharge summary

Instruct all staff nurses and typists to ensure the findings are included

The audit cycleProblem or objective

identified

Criteria agreed and standards

set

Data Collected (Audit)

Identify areas for improvement

Make necessary changes

Reaudit