Abstract
OBJECTIVE: This study employed an internal audit design to assess the completeness of patient discharge summaries at department of Surgery and allied specialties in Chaudhary Muhammad Akram Teaching and Research Hospital Lahore Pakistan. METHODS: The present audit was conducted at department of Surgery and allied specialties in Chaudhary Muhammad Akram Teaching and Research Hospital, Azra Naheed Medical College, Superior University Lahore Pakistan. Ethical approval was obtained from Institutional Ethical Review Committee maintaining patient confidentiality and data privacy. The initial audit was conducted on 105 discharge summaries of October to November 2024. A standardized checklist was used to assess the completeness the discharge summaries. Following this, targeted interventions aimed at improving documentation practices were done in December 2024. Subsequently, 95 patient discharge summaries from January and February 2025 were included in the re-audit using the same checklist was applied to assess the completeness of discharge summary documentation. Results of both audits were analyzed using SPSS version 23 and compared to determine the level of improvement in documentation completeness. RESULTS: The initial audit demonstrated compliance in documenting patient's hospital ID (104, 98.9%), full name (92, 87.6%), contact information (81, 77.1%), admission date (100, 95.2%), discharge date (94, 89.5%). There were gaps in areas such as pending investigations (73, 69.5%) and information on sent biopsies (66, 62.6%). The re-audit demonstrated improvements particularly in pending investigations (84, 88.4%), biopsy information (80, 84.2%) and red-flag symptoms (84, 88.4%), contact information (91, 95.8%) and follow-up appointments (89, 93.7%). However, the presenting complaint (92, 96.8%) and key treatments/procedures (89, 93.7%) showed slight decrease. CONCLUSIONS: The re-audit reflected a positive trend in documentation completeness, with most checklist items showing improved adherence compared to the original audit.