Mental Health Inpatient Discharge Standard

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.

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Current release

Version: v2.1
> Standard model – Excel
> Supporting documentation (external link to NHS Standards Directory)

From 01 January 2026, this standard will be owned and managed by NHS England and is made available for reuse or amendment under the Open Government Licence v3.0 (OGL 3.0). A review of the ongoing requirement for this standard will be undertaken by NHS England. Details on this and any update to the standard will be published on the NHS Standards Directory. If you have any questions or feedback relating to this standard, please email: england.standards.assurance@nhs.net.

 

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.

Summary table

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

Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.