Evaluation of computer generated neonatal discharge summaries

Abstract

Computer generated and dictated discharge summaries were compared for all 133 babies admitted for intensive and special care during a six month period. Whereas 130/133 (98%) had a computer generated summary, only 94/ 133 (71%) had a dictated summary. In addition, computerised summares were completed at discharge, but there was a delay up to 26 weeks for dictated summaries. Dictated summaries had more items of basic data missing but were more readable. A main diagnosis was missing in only 5/95 (5%) of dictated and 1/130 (1%) computerised summaries. Of the computer generated summares, 114/133 (86%) were suitable to give to parents. Satisfactory discharge summaries for babies requinrng intensive or special care can be generated with an on line computer system.