Improving electronic discharge summaries - phase two

The PRSB is developing detailed discharge summary information models that will put the right information in GPs’ hands to provide ongoing treatment for patients after discharge from hospital.


Improving electronic discharge summaries - phase two

Discharge summaries are important documents required for the on-going treatment of patients. When a patient moves from hospital to general practice care, pertinent information from the hospital record needs to be shared quickly to ensure that primary care clinicians have the information they need to deliver safe and effective care. This information needs to be both relevant and useful to GPs and their clinical teams as well as being practical for hospital clinicians to record.

The purpose of this project was to define the structure and content of the transfer of care information in consultation with patients, healthcare professionals and vendors to enable structured and coded (SNOMED CT) data on key clinical information (diagnoses, procedures, allergies and medications) to be communicated in electronic discharge summaries from hospital to GP practice. This will enable information to be incorporated into GP systems, following reconciliation, without rekeying, thus avoiding transcription errors and improving continuity of care.

Background

NHS Digital commissioned the Professional Record Standards Body (PRSB) to develop standardised electronic discharge summaries, based on the 2013 Academy of Medical Royal Colleges clinical record standards and on detailed medication models developed by Scottish Information Management in Practice (SCIMP).


This project was the second phase in the development of these standards. The first phase of the project, completed in April 2015, developed information models for 12 key headings in the discharge summary. The second phase focuses on medicines and on the validation of the previously developed information models for diagnoses, procedures, allergies and adverse reactions and some administrative headings.

Publication

The final version of the information models will provide the basis for NHS Digital to develop a technical message specification for implementation in the NHS in England, and use in the four nations as PRSB works across the UK.


The PRSB consulted on draft information models and implementation guidance in 2016 and produced drafts for final approval through our Advisory Board and endorsement by the key professional bodies involved in the development. The final drafts will be published as part of an overall update to the PRSB/Academy clinical records standards in early 2017.


For further information, please contact info@theprsb.org

Leave a comment




0 Previous Comments: