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 (revised May 2017) 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 standard was revised in May 2017 with updates focusing on medicines and on the validation of some of the previously developed information models.
eDischarge summary implementation guidance - This guidance sets out issues identified during the project which relate to the implementation of the headings and sub-headings. They are not intended to be comprehensive, but just those issues identified at this stage. It is expected that further guidance will be produced from the experience of initial implementations.
Transfers of Care clinical 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.
The standard contents - Mindmap version
View the eDischarge standard as a mindmap.
Please note: You will be able to view this in your browser without the need for Mindmap software.
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:
Draft technical (FHIR) specifications for eDischarge standard
The e-Discharge 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
- 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.