Risks to patient safety can occur on discharge from hospital, when vital information is not transferred quickly to GPs and community-based services. Best practice is also to share the discharge summary with the patient.
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 was an urgent need to improve patient safety and continuity of care by developing standardised e-discharge summaries.
The eDischarge 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.
Version 2 - Standard update
This standard has now been updated to version 2. Detailed release notes are available outlining the changes. These can be found in the supporting documents link above. Please select the contents tab (above) to view the standard in detail.
Supporting documents for the eDischarge summary standard
Implementation guidance report- eDischarge summary V2
This guidance sets out issues identified during the project which relate to the implementation of the headings and sub-headings.
Information model - eDischarge summary
View the standard as a detailed mindmap.
Final report - eDischarge summary standard
The final report outlines the process taken to reach the final standard.
Example of a discharge summary
This example discharge summary was developed as part of the e-discharge summary project. The purpose of the example is to demonstrate how the headings developed can be structured in a discharge summary for a patient in a given scenario (please see the scenario description above). The examples provided are not intended as exemplars of the way in which outpatient letters should be structured but simply to provide varied content to illustrate mapping to the PRSB standard. The example and scenario description were quality assured by the PRSB assurance committee.
Safety case report
The combined Clinical Safety Case document sets out the work done to manage clinical safety risks associated with four PRSB transfer of care projects between hospital and general practice. These include the e-discharge summary, mental health discharge summary, emergency care (EC) discharge summary and outpatient letter standards.
Hazard log - excel file
The Hazard Log records both generic and specific implementation hazards identified during the transfer of care projects. It includes associated mitigations and actions as well as guidance for system developers and implementers.
Transfer of care FHIR specifications
The eDischarge summary standard is endorsed by the following organisations:
- 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 Management
- 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.