Electronic discharge summary design: a step towards electronic health record ophthalmology patients.

backgroundFollow-up care management of patients post-discharge from hospital depends on effective communication systems, with discharge summary forms serving as the tool to facilitate information transfer between hospital care providers and follow-up. Paper forms are vulnerable to error and omission. Conversion to electronic systems can enhance accuracy and completeness of this information. This study aimed to design a prototype of an electronic discharge summary form specifically for ophthalmology inpatients.

methodThis five-phase study was performed in 2023. First, relevant articles from reputable databases were reviewed, followed by hospital reports, to achieve a minimum data set (MDS). Data validation was performed in two phases using the Delphi approach. Finally, the prototype electronic summary form was developed using Adobe XD.

resultsIn the first phase, 4704 articles were screened, yielding 12 relevant articles and identifying 612 data elements for the MDS. In the second phase, after screening 365 inpatient records, 139 data elements were gathered. The third phase yielded 128 final data elements, which were then validated via the Delphi method, ultimately confirming 123 elements across demographic information, examination details, hospitalization data, and discharge guidelines. Adobe XD was utilized to create the prototype.

conclusionThe ophthalmology-dedicated electronic discharge summary form enhances the quality of documentation and continuity of patient care, facilitates the collection of data for basic needs, and promotes smooth communication among caregivers to improve overall patient outcomes.