Improving Discharge Summary Follow-Up Documentation in a Major Trauma Center: A Two-Cycle Quality Improvement Project.

INTRODUCTION: Discharge summaries are critical for continuity of care, yet they often lack key information. Inadequate discharge documentation can lead to adverse events, medication errors, and poor follow-up of pending issues. We aimed to improve the completeness of discharge summaries-particularly follow-up instructions and communication to primary care-in a major trauma center, using standards from the Royal College of Physicians (RCP) Health Informatics Unit 2019 guidance. METHODS: We conducted a two-cycle quality improvement (QI) project in an orthopedic trauma unit of a Level I trauma center. In Cycle 1 (June-July 2025), we audited 33 discharge summaries against RCP-recommended content criteria (e.g. documentation of diagnoses, inpatient management, investigation results, medication changes, follow-up plans, general practitioner (GP) action items, and patient advice). Interventions implemented in August-September 2025 included staff education via posters, interactive teaching sessions, and team presentations to raise awareness of discharge summary standards. Cycle 2 (October 2025) reviewed 21 discharge summaries post-intervention. Following that, we compared documentation rates pre vs post intervention and used Fisher's exact test for categorical improvements and Mann-Whitney U for ordinal scores. RESULTS: Follow-up documentation improved from 15.6% to 90.0% (absolute difference +74.4%, 95% confidence interval (CI) +58% to +91%, p < 0.0001). Complete documentation of new medication indications increased from 9.4% to 50.0% (absolute difference +40.6%, 95% CI +17% to +61%, p = 0.004). Comprehensive patient advice increased from 21.2% to 76.2% (+55.0%, 95% CI +31% to +79%, p = 0.0002). CONCLUSION: Targeted educational interventions led to substantial improvements in discharge summary quality, particularly in follow-up instructions, medication documentation, and patient communication. Ensuring these elements are clearly documented helps bridge the transition from hospital to community care. Our project demonstrates that even in a busy trauma setting, focused efforts can align practice with recommended standards, improving handover to primary care and potentially patient outcomes. Sustained education and periodic audits are recommended to maintain high standards of discharge documentation.