E-discharge summary standard

PRSB electronic discharge summary standard to improve information sharing for patients discharged from hospital to GP care.

Electronic Discharge Summaries

Risks to patient safety can occur on discharge from hospital, when vital information is not transferred quickly to GPs and community-based services. Up until now there have been no common standards for the way that information is recorded in discharge summaries, which means that it often needs to be re-entered on GP computer systems, which risks errors occurring. There is an urgent need to improve patient safety and continuity of care by developing standardised e-discharge summaries.

In 2013 the first phase of the project tested standards for the clinical structure and information contained in patient records. As a result, requirements for 12 key information categories including patient demographic details, medications etc were developed for the hospital discharge summary record. The project report details these outcomes . Mind maps and spreadsheets for the information models can be found in the E-discharge summary standard. There is an over-arching mind map and 12 maps that correspond to the information models.

The second phase of this work, which is due to be completed in early 2017, focuses in greater detail on medicines and on the validation of the previously developed information requirements for diagnoses, procedures, allergies and adverse reactions and a review of all the other structured information needed for discharge records. Once complete, NHS Digital will develop technical specifications so that the information in e-discharge summaries can be turned into coded (SNOMED CT) data that can be shared reliably between care providers in real time and improve continuity of care. These coded e- discharge summaries are required through the NHS Standard contract for acute services.

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