Aplicación de sanciones judiciales y administrativas a los responsables de las violaciones

The system used for data entry inevitably contributes the features of the discharge summaries. There are at least three modes of data entry for completing discharge summaries identified in the current practice in the case study NHS Hospital Trust. Two of them are related to the paper record systems, the third is related to an electronic record which is currently being implemented in some of the wards. Each of these modes differs in terms of data entry and structure as described below.

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5.2. 4.1 Handwriting on proforma

A TTO was normally hand written on paper proforma, with a fixed structure and format, and signed. This mode of data entry is essentially designed for speed. It is handwritten and can be completed quickly and at any location in the hospital. The structure and headings act as prompts and data entry guidance. The prompts are generally useful for junior doctors who have less experience to make sure that important information is not omitted:

“for somebody who doesn’t do very many, for the new doctors, it’s really important to have those headings, so that they remember that’s what the GP needs to know.”

(Registrar 04 in Simulation Interview)

However, there are several drawbacks associated with the TTO’s data entry. The fixed structure and format of the proforma can be restrictive, and the handwritten data is often illegible:

“There’s only very, like one line for each heading on the TTO, so there’s not enough room to include all the information you might want to include, and also the headings are quite descriptive, so it’s not, you can’t often put the information you want under those headings. On the discharge summary (full discharge summary) you can do that, yeah.

(Registrar 05 in General Interview)

“But that’s for simple things like hernias and lumps and bumps and things like that, where you can have a generic sheet (TTO) as it were, because it’s simple non complicated surgery. There’s a lot of things that I do and for the acute you can’t do that, there isn’t a proforma that you can just suddenly populate, yeah?

(Consultant 02 in General Interview)

Another informant offered a strategy to deal with the rigidness of a proforma.

“I know what I want to write and I often cross off these headings, presentation, investigations, progress, because I just want to write a paragraph, ok.”

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5.2. 4.2 Dictation and typing

In contrast to a TTO, a full discharge summary normally is dictated by a doctor and transcribed by a secretary. These are essentially two different processes; dictation is a data entry process, while transcribing is a process of presenting output. The division of labour between data entry and the output process was driven by two objectives; to remove the requirement for a doctor to type the letter, and to increase legibility. Dictation is time efficient for doctors and allows them, at the same time, to scan through patient notes. The dictation seems to reduce the multitasking burden on doctors. Additionally, data entry through dictation allows doctors a freedom to express the patient case in a full narrative style with no page limitations:

“I can dictate anything I want, that can be as long as I want”

(Registrar 04 in General Interview)

Using dictation may give a false impression that there is no structure in full discharge summaries. Indeed, all informants agreed that they have a structure for dictating the letters.

However, that structure may again differ from one doctor to another:

“Even in the narrative, I have some structure to what I say, yeah. Some people in their narrative actually put much more structure, they will say admitted this date, discharged that date, you know, this diagnosis, you know, people would put, I don’t put that structure into it, but I mean I do it sort of sub consciously.”

(Consultant 02 in General Interview)

“There isn’t a nationally recognised structure, but different consultants like certain structures, so I think it’s good to have a structure which is something like date of admission, presenting complaint, progress, diagnosis, complications, so you have the sub headings. So although it might be prose, it’s still set out into the headings and a structure.”

(Registrar 08 in General Interview)

The pattern used in dictation provides a structure for the secretaries who transcribe and type the discharge summaries:

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“Yes, there’s a pattern to make it easier for the secretaries, ok, cos, yeah, erm, so you would dictate that first, so that they know they’ve got the right patient notes and they’ve opened the right file on their computer. So that’s the first thing you must say and then you start off with the date of admission and discharge, so they know they’re talking about the right thingy, and then dear doctor, and then you’ve got to find the name of their GP, ok, and then you tend to write reason for admission, and then it tends to be just sort of one word at the top, so it can just be chest pain, or you know, pneumonia or whatever”

(Registrar 04 in General Interview)

Dictation may free a doctor from the necessity of typing a discharge summary themselves, but she/he still has to include instructions about grammar and format to guide the secretary. Thus, dictation by a doctor who completes a full discharge summary completion must not be considered as a normal speech. It should be seen as “writing” with voice:

“When we dictate, we’re quite strict, so I would, I run the Falls Clinic, so you dictate all your grammar and everything as well [...] this lady has undergone a complete falls assessment, open brackets detailed overleaf, close brackets, and our recommendations are as follows, 1), such and such, 2), such and such. So we, yeah, you dictate your stops, you dictate everything, yeah.”

(Registrar 04 in General Interview)

One randomised controlled study suggested that providing a standard template for dictating improved quality of content, decreased the time length of data entry, and made a more concise discharge summary letter (Rao et al., 2005)

5.2. 4.3 Electronic application data entry

The introduction of electronic discharge summary records is driven by the many limitations of paper records. Illegibility, routing, access, retrieval, and slow transmission speed have all been recognised. An electronic discharge summary system is expected to overcome these limitations.

In an electronic discharge summary system, the data is entered (typed), guided by a clinical application user interface. One of the key benefits of an electronic application is that the computer can be programmed to control the data entry. For

135 example, the application can force users to fill mandatory data entry fields. This is not possible with the paper proforma and/or dictation:

“the electronic discharge summary is very clever, if you won’t fill every box, you can’t fill out the discharge letter. You have to fill out everything, very

comprehensive.”

(Registrar 09 in General Interview)

The mandatory field feature ensures completeness of data entry. The usefulness of this feature was seen as significant for increasing safety in the transmission of information related to medication changes to GPs:

“The electronic discharge prompts you at certain points, especially when you come to drugs, to know exactly whether you’ve changed something. So you can’t complete the electronic discharge without specifying whether you’ve changed the drug and stating the reason for either stopping a drug or starting a drug. So I think it’s very good in that way, it’s very good for fool proof.”

(Consultant 10 in General Interview)

The discharge summary application is normally implemented as a part of patient electronic medical record management systems7. Some information in a discharge summary such as patient admission and discharge details or medications can be easily imported from data already input to the system. Thus, the data in the discharge summary is more likely to be consistent.

In an electronic system, data entry, clinical record, and the printed version of clinical records can be structured independently. This separation allows the discharge summary printed out to be formatted dynamically based on the

information provided at data entry. With a paper proforma, many irrelevant field may be left empty and the reader may not know if this is an omission, or not applicable. Although the electronic discharge summary system is not error proof as the person responsible for data entry may still omit important information, empty fields can be hidden from the final print out in order to provide a better

7

The electronic patient record management system in the hospital is often called patient administration system (PAS).

136 reading view. Also a number of strategies can be programmed to force data entry or require non empty fields in order to proceed thereby reducing an unconscious omission.