Mental Health Inpatient Discharge Standard
People with mental health problems require comprehensive, integrated physical and mental health care, both in hospital and the community. The PRSB has developed the Mental Health Inpatient Discharge Summary Standard to ensure that relevant information is shared among healthcare professionals, facilitating continuity of care when an adult is discharged from inpatient mental health services.
Current release
The standard | |
|---|---|
Full standard – PRSB viewer | Available with next release |
Full standard – Excel | Download file (Excel) |
Full standard – Json | Available with next release |
Supporting documentation | Description/purpose |
|---|---|
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 Mental Health Inpatient Discharge Standard. |
Business rules (not available until next release). | 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. |
Need implementation support?
- Online support form
- Support@theprsb.org
- 020 4551 5225 (9-5 Mon-Fri, excl. bank holidays)
About this standard
The Mental Health Inpatient Discharge Summary Standard is designed to improve communication between secondary care providers and GPs. It ensures that timely and relevant information about a person’s care and treatment is accessible to GPs, community and acute mental health care teams, and social care professionals. This standard includes details on patient history, social context, medications, hospital admission details, and current and previous diagnoses. By recognising the unique nature of mental illness compared to physical illness, the standard uses inclusive and sympathetic language in its headings and clinical descriptions. This project supports NHS England’s interoperability efforts.
Benefits:
- Enhances professional communication and continuity of care.
- Ensures timely access to relevant patient information.
- Supports integrated care across different healthcare settings.
- Uses inclusive language tailored to mental health care.
Scope
Adult discharge from inpatient mental health services
Out of Scope
- Discharge from non-mental health inpatient stay – refer to the eDischarge Summary Standard – PRSB (theprsb.org)
- Discharge from emergency care – refer to the Emergency Care Discharge Standard – PRSB (theprsb.org)
- Transfer between hospitals – although much of the content may be appropriate
- Discharge from outpatient treatment or other community basedcommunity-based period of treatment – refer to Outpatient letter v2.2 – PRSB (theprsb.org)
How it works
The Mental Health Inpatient Discharge Summary Standard operates by ensuring that all relevant information is recorded and shared in a structured and coded format. This facilitates seamless communication and continuity of care across different healthcare settings.
Below is a summary table of the standard which comprises 23 sections, 5 mandatory (must be included), 12 required (should be included where the information is available), 6 optional (local choice whether to include the information):
| Section | Description | MRO* |
| Patient demographics | Patient details and contact information. | mandatory |
| GP practice | Details of the GP practice where the patient is registered. | mandatory |
| Referrer details | Details of the individual or team who referred the patient. | required |
| Social context | The social setting in which the patient lives, such as their household, occupational history, and lifestyle factors. | optional |
| Individual requirements | Individual requirements that a person has, e.g. communication, cultural, cognitive, mobility needs and reasonable adjustments. | required |
| Participation in research | The details of any research studies the patient is participating in. | required |
| Admission details | Details of the patient’s admission and reason for admission | required |
| Discharge details | The details of the patient’s discharge including discharge destination. | required |
| Diagnoses | A list of the patient’s diagnoses. | required |
| Procedures | The details of any procedures performed or therapies undertaken. | optional |
| Clinical summary | A brief description of the episode of care. | mandatory |
| Family history | Information on illness in family relations relevant to the health or care of the patient | optional |
| Investigation results | A record of investigations and procedures requested, results and plans. | optional |
| Assessments | A description of any assessments used. | optional |
| Legal information | Legal information captured relating to patient care, such as consent to sharing information, legal power of attorney, safeguarding issues and mental capacity. | required |
| Safety alerts | The details of any risks the patient poses to themselves or others. | required |
| Medications and Medical Devices | The details of and instructions for medications and medical equipment the patient is using. Includes changes in prescribed medications. | optional |
| Allergies and adverse reactions | The details of any known allergies, intolerances or adverse reactions. | mandatory |
| Patient and carer concerns, expectations and wishes | A description of the concerns, expectations or wishes of the patient. | required |
| Information and advice given | A record of any information or advice given to the patient, carer or relevant third party. | required |
| Plan and requested actions | Plans and requested actions for other healthcare professionals and the patient or their carer, including planned investigations, procedures and treatment. | required |
| Person completing record | The details of the person who filled out the record. | mandatory |
| Distribution list | A list of other individuals to receive a copy of this communication. | required |
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.
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
Further resources
- 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.
Endorsement
- Association of Directors of Adult Social Services
- British Psychological Society
- Royal College of Anaesthetists
- Royal College of Psychiatrists
- Royal College of General Practitioners
- Royal College of Occupational Therapists
- Royal Pharmaceutical Society
- Institute of Health Records and Information Management
- TechUK