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Background. A discharge summary may be the only available health record for a patient, especially in resource-limited settings with suboptimal record-keeping. Considering the risk of adverse neurodevelopmental outcomes secondary to hypoxic ischaemic encephalopathy (HIE) and litigation, the quality of summaries for neonates with HIE is particularly important.
Objectives. To audit electronic discharge summaries of neonates admitted with HIE to two tertiary hospitals in [City], South Africa.
Methods. A retrospective, quantitative study was conducted. Electronic discharge summaries of late preterm and term neonates with HIE, admitted in 2018 and 2019 were audited for relevant information: final diagnosis, birth history, clinical evaluation, management, investigations, plan at discharge, and counselling of parents.
Results. Of the 165 identified cases, 34 (20.6%) were excluded. Ten patients did not have electronic discharge summaries. Details of the other 24 cases in admission registers were incomplete. The final diagnosis of HIE appeared in 87 (66.4%) of 131 audited summaries. More than half (52.7%) lacked correct ICD-10 coding for HIE. Information on foetal distress and sentinel events was absent in 61.1% and 42.0%. Requirement for resuscitation was recorded in 90.8% of summaries. Performance of cardiac compressions and adrenaline administration were not specified in 46.6% and 54.2%. Admission blood gas results, particularly base deficit, lactate and glucose, were absent in 42.7%, 63.4% and 90.8% of summaries. Eligibility for therapeutic hypothermia was not captured in 41.2%. Cranial ultrasound, neuro-imaging, exclusion of meningitis, or multisystem involvement was not mentioned in 80.9%, 99.2%, 80.2% and 96.2%, respectively. Notes on counselling of parents were lacking (83.2%). Final cause of death was unspecified in 12 of 14 (85.7%) patients who died.
Conclusion. Discharge summaries of neonates at risk of adverse neurodevelopmental outcomes secondary to HIE lacked essential information. Quality improvement and regular auditing of patient records must be prioritised.
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