Summary
Type:
Information standards
Topics:
- Care records
- Continuity of care
- Demographics
- Information governance
- Key care information
- Patient communication
- Pharmacy, Medicines and Prescribing
- Referrals
- Tests and diagnostics
Care Settings:
- Community health
- Hospital
- Social care
Contact Point
Contact Point:
Documentation
Description:
The eDischarge Summary Standard enables hospitals to safely transfer accurate clinical information and coded data to GP surgeries, care homes and community services when a patient is discharged. It ensures all relevant information about the patient, including diagnoses, medications, procedures and allergies, is shared in order to improve the quality and consistency of care. Best practice is also to share the discharge summary with the patient.
About this standard
The standard defines the information content and structure that should be used to create a hospital discharge. It is designed for sending coded and structured electronic discharges which can be transferred to primary care and other systems and used to populate their record systems. Full electronic transfer will improve safety through reducing the risk from re-typing information and make that information fully available in the receiving electronic record systems and more quickly. It can also be used for paper or electronic documents, although some of the benefits will not be realised in doing this.
The expected benefits:
-Improved patient safety:
- Having information which is needed for safe continuity of care available on a timely basis.
- Avoiding transcription errors when medication information is electronically transferred to the GP record (following clinician review), without the need for re-entry.
- Improvements to patient care and patient satisfaction:
- Having consistent and timely information (including medications, diagnoses, procedures and allergies) transferred to all relevant care professionals and their GP practice.
- Providing patients with legible up to date information about their stay in hospital.
- Support for new more integrated and person-centred ways of working, including increased efficiency for multidisciplinary teams by providing structured and coded information on diagnoses, procedures and medications which can be reused for new ways of integrated working across health and care.
- Time savings for NHS organisations by avoiding the need to re-type information into the GP record
- Increased opportunity for future development of patient-led care by ensuring interoperability between multiple systems, including personal health records.
- Discharge from emergency care – refer to the Emergency Care Discharge Standard.
- Discharge after mental health inpatient stay – refer to the Mental Health Inpatient Discharge Standard.
- Transfer between hospitals – although much of the content may be appropriate.
- Discharge from outpatient treatment or other community based period of treatment – refer to the Outpatient Letter Standard.
Documentation Link:
Relations:
Name:DCB1605: Accessible Information
Name:NICE guideline (NG27)
Name:Transfer of Care Inpatient Discharge - FHIR
Is Part Of:
Name:Transfer of Care Initiative
Explanation:The Transfer of Care initiative has been mandated by the NHS Standard Contract.
It includes a group of related standards covering inpatient, emergency care,
mental health and outpatient settings.
Dependencies:
This standard needs to be reviewed and implemented alongside:
Name:SNOMED CT
Name:Health Level 7 Fast Healthcare Interoperability Resources (FHIR)
Explanation:Health Level 7 Fast Healthcare Interoperability Resources (HL7 FHIR) is a
standard for health care data exchange, published by HL7®.
Name:Electronic systems both sending and receiving
Name:Transfer of Care - Acute Inpatient Discharge Standard
Url:https://standards.nhs.uk/published-standards/transfer-of-care-acute-inpatient-discharge-standard
Explanation:DAPB4042
Review & Status
Contributor:
Professional Record Standards Body
Dataset Identifier:
9e4fb1fa-c387-48b6-a3b4-b713c85bd568
Mandated:
No
Status:
active
Origin
Name:
NHSE-SD Data Catalogue