Core Information Standard

The eDischarge Summary Standard enables hospitals to safely transfer accurate clinical information and coded data to GP surgeries, care homes and community services when a patient is discharged. It ensures all relevant information about the patient, including diagnoses, medications, procedures and allergies, is shared in order to improve the quality and consistency of care. Best practice is also to share the discharge summary with the patient.

Current release

Version: V2.1
Release date
December 2019
Release notes
V2.1
V2.0
V1.1
Next release date
December 2024
Next release type
Scheduled release
The standard
Full standard – PRSB viewer
Available with next release (Dec 24)
Full standard – Excel
Download file (Excel)
Full standard – Json
Available with next release (Dec 24)
Minimum Viable Information Standard (MVIS)
MVIS sets out the data items and business rules that must be implemented to achieve safe, minimum implementation . Read more >
Supporting documentation
Description/purpose
Information standards notice (ISN)
ISNs are published to announce new or changes to information standards published under section 250 of the Health and Social Care Act 2012.
FHIR technical specifications
The messaging specification for exchanging information using the NHS standard for messaging, HL7 FHIR.
Implementation guidance
This document includes general implementation guidance for all PRSB standards and detailed guidance, specific to the eDischarge Summary Standard.
eDischarge implementation toolkit
A step-by-step guide to help suppliers and organisations implement the standard.
Business rules
Rules for implementation of the standard.
Final report
Describes the purpose, methodolgy and stakeholder engagement for developing the standard, along with the findings and recommendations for further work.
Safety case
Summarises the hazards which could result from implementing the standard.
Hazard log
Details the potential hazards from implementing the standard with their risk rating and mitigation.
Provenance data
Defines the information on who made a record entry and who carried out the activity, where and when.
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Partners at work

comformant partners

The following PRSB Partners have successfully achieved conformance against this standard.

About this standard

The standard defines the information content and structure that should be used to create a hospital discharge. It is designed for sending coded and structured electronic discharges which can be transferred to primary care and other systems and used to populate their record systems. Full electronic transfer will improve safety through reducing the risk from re-typing information of information and make that information fully available in the receiving electronic record systems and more quickly. It can also be used for paper or electronic documents, although some of the benefits will not be realised in doing this.

 The expected benefits:

  • Improved patient safety:
    • Having information which is needed for safe continuity of care available on a timely basis.
    • Avoiding transcription errors when medication information is electronically transferred to the GP record (following clinician review), without the need for re-entry.
  • Improvements to patient care and patient satisfaction:
    • Having consistent and timely information (including medications, diagnoses, procedures and allergies) transferred to all relevant care professionals and their GP practice.
    • Providing patients with legible up to date information about their stay in hospital.
  • Support for new more integrated and person-centred ways of working, including increased efficiency for multidisciplinary teams by providing structured and coded information on diagnoses, procedures and medications which can be reused for new ways of integrated working across health and care.
  • Time savings for NHS organisations by avoiding the need to re-type information into the GP record
  • Increased opportunity for future development of patient-led care by ensuring interoperability between multiple systems, including personal health records.

The standard is evidence-based and developed through extensive consultation with clinicians, professionals and people across health and care involved with hospital discharge. Full details of how it was developed are available in the final report in the supporting information section below.

Scope

Discharge from hospital after any inpatient stay, including day cases.

Out of scope:

  • Discharge from emergency care – refer to the Emergency Care Discharge Standard.
  • Discharge after mental health inpatient stay – refer to the Mental Health Inpatient Discharge Standard.
  • Transfer between hospitals – although much of the content may be appropriate.
  • Discharge from outpatient treatment or other community based period of treatment – refer to the Outpatient Letter Standard.

How it works

The hospital electronic patient record (EPR) is expected to be able to generate much of the discharge summary from information recorded in the record such as diagnoses, procedures, medications, investigation results, assessments, patient demographics and other administrative information, with the person completing the record adding other information such as the clinical summary, plan and requested actions.

The standard comprises 22 sections, 6 mandatory (must be included), 10 required (should be included where the information is available), 6 optional (local choice whether to include the information). These are shown in the summary table below [create from file here: eDischarge-v2_1 Summary table.xlsx ]

 

eDischarge (V2.1) summary table 
SectionDescriptionMRO*
Patient demographicsPatient details and contact information.mandatory
GP practiceDetails of the GP practice where the patient is registered.mandatory
Referrer detailsDetails of the individual or team who referred the patient.required
Social contextThe social setting in which the patient lives, such as their household, occupational history, and lifestyle factors.optional
Individual requirementsIndividual requirements that a person has, e.g. communication, cultural, cognitive, mobility needs and reasonable adjustments.required
Participation in researchThe details of any research studies the patient is participating in.optional
Admission detailsDetails of the patient’s admission and reason for admissionrequired
Discharge detailsThe details of the patient’s discharge from hospital including discharge destination.required
DiagnosesA list of the patient’s diagnoses.mandatory
ProceduresThe details of any procedures performed.optional
Clinical summaryA brief description of the episode of care.mandatory
Investigation resultsA record of investigations and procedures requested, results and plans.optional
AssessmentsA description of any assessments used.optional
Legal informationLegal information captured relating to patient care, such as consent to sharing information, legal power of attorney, safeguaarding issues and mental capacity.required
Safety alertsThe details of any risks the patient poses to themselves or others.required
Medications and Medical DevicesThe details of and instructions for medications and medical equipment the patient is using. Includes changes in prescribed medications.optional
Allergies and adverse reactionsThe details of any known allergies, intolerances or adverse reactions.mandatory
Patient and carer concerns, expectations and wishesA description of the concerns, expectations or wishes of the patient.required
Information and advice givenA record of any information or advice given to the patient, carer or relevant third party.required
Plan and requested actionsPlans and requested actions for other healthcare professionals and the patient or their carer, including planned investigations, procedures and treatment.required
Person completing recordThe details of the person who filled out the record.mandatory
Distribution listA list of other individuals to receive a copy of this communication.required

*Conformance (MRO)
Conformance describes whether the element is mandatory (MUST be recorded or shared), required (SHOULD be recorded or shared if available) or optional (MAY be recorded or shared). These rules apply to the person recording or sharing the information.

For full implementation the discharge information should be sent as electronic message using the NHS standard for messaging, HL7 FHIR, detailed here: Transfer of Care message specifications – NHS England

 

Examples

To give a clearer idea of how the standard works in practice, PRSB have created a scenario example.

Further resources

  • Minimum viability information standard (MVIS)
    PRSB information standards define best practice based on evidence and widescale consultation and input from users and stakeholders. PRSB recognises that the NHS and social care are on a journey towards standardisation and interoperability and our aim is to support and encourage implementers on that journey. For this reason, we have defined and clinically validated a ‘Minimum Viable Information Standard (MVIS)’ for each of our standards which represent the minimum safe instance of the standard and delivers the intended objectives within the spirit of the standard. The MVIS defines the data items and business rules which must be implemented in order to have achieved this minimum instance. It is our aim that implementers will continue to improve their implementation of the standard over time and strive for a ‘best practice’ implementation, supported and evidenced by PRSB conformance testing. Please contact our support team to receive a copy of the MVIS for this standard.
  • Standards explained
    PRSB’s guide to standards which sets out the purpose and benefits of using standards and how to support frontline professionals to adopt them.
  • IHRIM record correction guidance
    Despite vigilance when filing information in records, mistakes can occur. The Institute of Health Records and Information Management has guidance to support professionals in making corrections following errors.
  • Transfers of care discovery report
    The eDischarge Summary Standard was first published in 2015. Despite significant investment in programme initiatives, the widespread implementation of the standards has been slow.
    In this report we identify the challenges that have inhibited the adoption of the standard, make recommendations for improvements and set out the anticipated benefits that this will bring.

Endorsement

  • Institute of Health Records and Information Management
  • Royal College General Practitioners
  • Royal College of Anaesthetists
  • Royal College of Midwives
  • Royal College of Nursing
  • Royal College of Obstetricians and Gynaecologists
  • Royal College of Paediatrics and Child Health
  • Royal College of Physicians
  • Royal College of Surgeons*
  • Royal Pharmaceutical Society
  • techUK

 

* 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.