Inclusion of Diagnostic Imaging in Orthopaedic Discharge Summaries: A Quality Improvement Project

Incomplete documentation of diagnostic imaging in discharge summaries is a recognised patient safety risk, particularly in orthopaedics, where radiological findings often guide management. Omission of imaging results can lead to duplicated investigations, delayed recognition of complications, and missed follow‑up. This audit evaluated the quality of imaging documentation in elective orthopaedic discharge summaries and assessed the impact of a targeted intervention.

To improve the inclusion of diagnostic imaging results on discharge summaries for elective orthopaedic inpatients.

A retrospective clinical audit with a re‑audit cycle was conducted on the elective orthopaedic ward at University College London Hospitals. The first cycle (1^st to 31^st July 2025) reviewed discharge summaries of all adult elective orthopaedic inpatients who underwent radiological investigations. Exclusion criteria were trauma admissions and patients without imaging. Data were extracted from the electronic patient record and radiology reporting system, recording whether imaging performed during admission was referenced in the discharge summary. Following the first cycle, an educational poster highlighting audit findings and national standards was disseminated to ward doctors. The introduction of the structured template with a mandatory "diagnostic imaging" section was also introduced. A re‑audit (1^st to 30^th September 2025) assessed the impact of this intervention. The primary outcome was the proportion of discharge summaries referencing relevant imaging results.

In the first cycle, none of the 144 eligible discharge summaries (0%) documented imaging results. Following ward doctor education and the introduction of the structured template with a mandatory "diagnostic imaging" section, compliance improved to 93%.

Embedding a dedicated diagnostic imaging section within discharge summaries eliminated omissions and ensured consistent communication of radiological findings. This simple, speciality-specific intervention directly addressed a critical documentation gap in orthopaedics and represents a scalable, evidence‑based strategy to strengthen clinical handover and improve patient safety.