Trauma Ward Mental Health Discharge Summary Handoff Completeness and Post-Traumatic Stress Disorder Referral Failure Among Malawian District Clinicians: A Multilevel Analysis of Documentation Fragmentation

In Malawi's district hospitals, the handoff of trauma survivors from emergency wards to mental health services depends on the completeness of discharge summaries, yet the relationship between documentation fragmentation and post-traumatic stress disorder (PTSD) referral failure remains poorly specified. The model is formalised as a two-level logistic framework in which patients are nested within wards, and ward-level completeness is treated as a latent construct measured by multiple indicators. Using published evidence on trauma care in Malawi and comparable settings, the paper derives testable propositions about the conditions under which documentation fragmentation produces referral failure. The effect of completeness on referral is moderated by clinician seniority and by the availability of a designated mental health focal person, and that fragmentation operates primarily through interruption of the referral pathway rather than through information decay alone.