NEWBORN DISCHARGE LETTER AS A COMMUNICATION DOCUMENT FOR CONTINUITY OF CARE

AIMS: To check information items in newborn discharge letters from various delivery rooms and compare them to the expectations of community pediatricians.

BACKGROUND: The newborn discharge letter is the document that supports the transition of care from the hospital stay to life at home and in the community. It usually summarizes medical information related to the baby's family, maternal pregnancies, delivery and the stay in hospital until discharge. It is primarily a communication tool between healthcare professionals. It is also a legal document that records basic anthropomorphic and physiologic measurements.

METHODS: A comparison of items in discharge letters and a survey among pediatricians.

RESULTS: A survey of 104 community pediatricians revealed that the most important information that is expected to appear in a discharge letter includes duration of pregnancy, mode of delivery, APGAR score, birth weight, head circumference, weight at the time of discharge, and the results of hearing screening test and red reflex in the examination of the eyes. Except for the red reflex, all this information appears in the discharge letters of the 19 hospital delivery centers that were checked. Items of information that were rated less important for the community pediatricians were history of previous pregnancies, maternal blood type, time of delivery, baby's length and size of the fontanelle. Inconsistency in the presentation of information in discharge letters was the major concern indicated by community pediatricians. There was a major difference between hospitals with regard to the detailing of instructions to parents about the baby's safety, feeding, and further follow-up in the community.

CONCLUSIONS: It is desirable that newborn discharge letters from different hospitals will have more uniformity and more detailed information.