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Arch Dis Child. 1991 April; 66(4 Spec No): 433–436.
PMCID: PMC1590307

Evaluation of computer generated neonatal discharge summaries.


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 summaries 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 summaries, 114/133 (86%) were suitable to give to parents. Satisfactory discharge summaries for babies requiring intensive or special care can be generated with an on line computer system.

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Selected References

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  • Maresh M, Beard RW, Combe D, Dawson AM, Gillmer MD, Smith G, Steer PJ. Selection of an obstetric data base for a microcomputer and its use for on-line production of birth notification forms, discharge summaries and perinatal audit. Br J Obstet Gynaecol. 1983 Mar;90(3):227–231. [PubMed]
  • Maresh M, Dawson AM, Beard RW. Assessment of an on-line computerized perinatal data collection and information system. Br J Obstet Gynaecol. 1986 Dec;93(12):1239–1245. [PubMed]

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