eDischarge summary v2.1
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 eDischarge 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 eDischarge Summary standard has now achieved ISN status following rigorous quality assurance by the NHS Data Alliance Partnership Board.
- 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
* 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.
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.