Background: Inadequate discharge documentation at Almanagil Teaching Hospital posed significant risks to patient safety and continuity of care, consistent with challenges seen in similar healthcare settings. The hospital aimed to address these gaps by enhancing the completeness, accuracy, and clarity of surgical discharge documentation through the development and implementation of a standardized discharge card, coupled with targeted staff training. Methods: A prospective quality improvement project was conducted in two cycles (May-June 2025), involving audits of 44 (First Cycle) and 51 (Second Cycle) surgical discharge cards. Following baseline assessments, a structured discharge card was developed and implemented, along with targeted clinical staff training. Results: Post-intervention audits revealed substantial improvements. Documentation of telephone number and address rose from 0 (0%) to 47 (92.2%) and 49 (96.1%), respectively. The number of hospital file entries increased from 29 (65.9%) to 49 (96.1%). Referrers' names, roles, organizations, and contact details improved from less than three (6.8%) to 51 (100%). Clinical elements, such as documentation of intraoperative and postoperative complications, rose from nine (20.5%) and eight (18.2%) to 51 (100%). Overall compliance increased from 52.9% to 94.6%, marking a 41.7% gain. Conclusion: The intervention significantly enhanced discharge documentation quality, reinforcing standardization, patient safety, and accountability. The model is scalable to similar resource-limited settings and warrants sustained auditing and ongoing training for long-term impact.
Muhammed et al. (Thu,) studied this question.