31 May 2017
E-discharge summary standard - revised
PRSB has developed detailed clinical information models for the revised electronic discharge summary standard. The revised standard has now been published and focuses on medicines and on the validation of some of the previously developed information models.
The revised e-Discharge Summary Standard enables hospitals to safely transfer standardised clinical information using PRSB headings and coded data (SNOMED CT and dm+d) which can be extracted directly into GP IT systems, when a patient is discharged from hospital care. The e-Discharge Summary Standard will ensure all relevant information on diagnoses, medications, procedures and allergies about a patients is shared with GPs in order to improve the quality and consistency of care.
The revised e-Discharge Summary Standard was produced in two phases. The first phase of the project, completed in April 2015, developed information models for 11 key headings in the discharge summary. The second phase focused on medicines and on the validation of the previously developed information models for diagnoses, procedures, allergies and adverse reactions and some administrative headings.
NHS Digital has developed technical standards that support the interoperability of the e-Discharge Summary. As part of the standard NHS contract, providers are required to use PRSB headings to structure the content of the discharge summary and from October 2018 they will be need to send structured and coded discharge summaries to GPs.
The e-Discharge Summary Standard also provides implementation guidance, which will be supplemented by case studies of trusts which implement the standard and learning resources which will also be available on the PRSB website in due course.
Example of an E-Discharge summary
Each information model has a set of headings and definitions for the e-discharge summary standard. These are listed below;
|Allergies and adverse reaction - revised MAY 2017|
|Diagnoses - revised MAY 2017|
|Procedures - revised MAY 2017|
|Medications and medical devices - revised MAY 2017|
|Other discharge summary headings - revised MAY 2017|
- Royal College General Practitioners
- Royal College of Physicians
- Royal Pharmaceutical Society
- Royal College of Nursing
- Royal College of Midwives
- Royal College of Obstetricians and Gynaecologists
- Royal College of Paediatrics and Child Health
- Royal College of Anaesthetists
- Institute of Health Records and Information
- Royal College of Surgeons*
* This standard has been endorsed by our members and sets the direction which all organisations, professionals and clinicians should be working towards. Members agree that clinical information standards are essential but are not enough to deliver the 'Clinical Vision 2020' and unless and until these standards are underpinned with corresponding technical and system improvements and the funding required to achieve adoption, a fully digitised health and care system is not achievable in prescribed timescales. The PRSB and its members will work to ensure key stakeholders are sighted on these current limiting factors and act on them and we will influence suppliers to deliver appropriate systems that enable use of clinical information standards, without increasing burden.