Effect of a structured training programme for doctors on the completeness of discharge summaries at a Nigerian tertiary hospital: a before-and-after document audit

                @article{CRSIJ26000495,
                  author = {Ayoola Sunday Ekundayo, Best Ordinioha, Jacob Kehinde Opele},
                  title = {Effect of a structured training programme for doctors on the completeness of discharge summaries at a Nigerian tertiary hospital: a before-and-after document audit},
                  journal = {Cosmo Research and Science International Journal},
                  year = {2026},
                  volume = {2},
                  number = {2},
                  pages = {964-971},
                  issn = {3108-1584},
                  url = {https://cosmorsij.com/published/CRSIJ26000495.pdf},
                  abstract = {The discharge summary is the main written record that links a hospital stay to later care, and the source from which diagnoses are coded. In many Nigerian tertiary hospitals, discharge summary forms are incompletely filled, but there is little objective evidence on whether short, structured training for doctors improves this. To assess the effect of a structured training programme on the completeness of discharge summaries at the Federal Medical Centre (FMC), Owo, Ondo State, Southwest Nigeria. One-group pre-test–post-test (before-and-after) study with no control group. Doctors received a structured discharge summary training programme in April 2025. Completeness was audited in 351 randomly sampled discharge folders from the year before training (1 April 2024 to 31 March 2025) and 351 different folders from the year after (1 May 2025 to 30 April 2026), 702 folders in total, drawn from about 3,996 discharges per year. A 19-item checklist derived from the hospital's own discharge summary form was used. The composite score for each folder was the percentage of applicable items marked complete. Groups were compared with an independent-samples t-test. Mean composite completeness rose from 55.0% (SD 15.4) to 90.3% (SD 11.2), a difference of 35.3 percentage points (95% CI 33.3 to 37.3; t = 34.72, df = 700, p < 0.001; standardised mean difference about 2.6). Every one of the 19 items improved. Patient identifiers were already well recorded at baseline (mean 91.0% of folders) and changed little (98.9% after). The largest gains were in diagnostic and procedural fields (36.1% to 84.0%) and in fields that identify who completed and signed the form (42.7% to 87.8%). Principal diagnosis was complete in 46.7% of folders before training and 90.9% after; the doctor's signature was present in 42.7% and 88.3%. Completeness of discharge summaries was substantially higher in the year after a two-day structured training programme than in the year before. Because there was no control group, the design cannot exclude other explanations for the change, but the size and consistency of the improvement across all 19 items support the use of structured training, with a standard template and periodic audit, to improve discharge documentation in comparable settings. Controlled and longer-term studies are needed.},
                  keywords = {Discharge summary, clinical documentation, health data quality, training, health information management, Nigeria, tertiary hospital},
                  month = {September}
        }