(Redirected from Discharge summary
When discharging from hospital, it is customary to send written information to the patient's GP. This is more than merely courtesy as the discharge letter serves as important vehicle of communication between primary and secondary care. It should aim to provide the GP with enough information to resume adequate care in the community. Do consider verbal contact in exceptional circumstances. Secure electronic communication is being introduced in the UK.
There are often 2 separate parts:
- An immediate discharge letter dispatched on the same day or sometimes passed to the patient.
- A more detailed letter sent somewhat later as this is often dictated, typed and filed. It is often called a Discharge Summary.
Suggested Content and Structure
This can usefully include
- Significant investigations
- Treatment in Hospital
- Medication on discharge
- Future Hospital Plans
|If you changed something, say why, not just what|
The national contract 2009/10 specifies that "The Provider must
- at the time of a patients discharge...issue a discharge letter
- complete and issue a Discharge Summary within improving timescales – within:
- 72 hours from 1st April 2009
- 48 hours from 1st April 2010
- 24 hours from 1st April 2011
Defines the contents of each to include:
- Discharge Letter
- Patient’s demographics
- Dates of admission and discharge
- Details of any clinical procedure
- Name of the responsible lead clinician or Consultant at discharge
- Details of any medication prescribed at discharge
- Any other relevant or necessary information or instructions
- Contact details
- Discharge Summary
- ...shall be easily legible...
- Date of admission
- Date of discharge
- Details of any Services provided, including any operation(s) and diagnostic procedures performed and their outcomes
- Summary of the key diagnosis made during the admission
- Details of any medication prescribed at the time of discharge
- Any adverse reactions or allergies to medications or treatments observed during admission
- Name of the responsible Consultant at the time of discharge
- Any immediate post-discharge requirement from the primary healthcare team
- Any planned follow-up arrangements
- Whether any relevant infection, for example MRSA
- Name and position of the person to whom questions about the contents of the Discharge Summary may be addressed, and complete and accurate contact details (including a telephone number) for that person
The following headings provide a guide. It is suggested for NHS use you use the official documents as the headings are standardised for the electronic patient record:
- Patient Details
- M / F
- Date of Birth
- NHS No.
- Hosp No.
- Tel No.
- Admission and GP Details
- Discharging Consultant
- Discharging Speciality/Department
- Method of Admission
- Date of Discharge
- Date of Discharge
- G.P. Details
- Diagnosis at Discharge
- Operations and Procedures
- Reason for Admission and Presenting Complaint(s)
- Clinical Narrative
- Relevant Investigations and Results
- Discharge Destination
- Relevant legal Information
- Information given to patient and/or authorised representative
- Physical Ability & Cognitive Function
- Advice, recommendations and future plans (including results awaited and outstanding investigations)
- Actions and Outstanding Investigations
- Medications Stopped/Changed
- Allergies/ Risks & Warnings
- Discharge Medications
- Compliance aid?
- Details of Discharging Doctor
- Doctors Signature
- Contact No.
This article is a work in progress. Please feel free to contribute to it.