What you need and don’t need in a discharge summary

When you are creating a discharge summary, have you ever thought about the person receiving it? Maybe it’s time to consider what information actually makes a quality discharge summary.

As time-consuming and complex as it is, and at times when it seems to be a lesser priority on your to-do list, we need to remember that discharge summaries are important. Often, the discharge summary is the only form of communication that accompanies the patient to their next setting of care. High-quality discharge summaries are thought to be critical to patient outcomes, reducing the risk of re-hospitalisation when a patient is provided with a timely follow-up.

It is also the sole communication between the hospital and the GP, and GPs rely on discharge summaries to verify the patient’s history and help with continuity of care. In the post-hospital period, we need to better enable GPs by providing the right information, at the right time, in the right format, to ensure a continued high-quality care for the patient.

What to consider:

     1. Security and health data capture from the beginning

Now more than ever, it should be easier to have discharge summaries which are accurate and of high quality with the rise in use of My Health Record and electronic discharge summaries. This information can be shared directly with GPs via Secure Messaging, and includes information captured from admission right through to discharge. Therefore, it is important to ensure the GP’s contact details are correct for privacy and security reasons. It is also important to include the early involvement of all allied health and community services to have a holistic view of the patient information.

     2. Considered and concise information

A discharge summary should be a considered and concise document of the major events a patient has experienced throughout an admission. Only include the information which will inform the GP of the patient’s current level of function and the status of their chronic conditions at the time of discharge. Including every detail, small and large is not required, and only drowns out the information which should be focussed on.

     3. Clear medication history

It is important to include why medications were stopped, started, removed and used while in hospital, as well as when a patient should restart them. Medications are adjusted frequently throughout admission to discharge, and for continuity of their care a GP needs to have access to this accurate information.

     4. Key information and results upfront

Discharge summaries can be detail heavy and daily changes are documented throughout the hospital admission. However, for ease of review it is important that the final results and changes prior to discharge are the most prominent. Information which the GP is required to follow up on should also be clearly noticeable and noted upfront on the summary so the GP won’t miss them.

      5. Follow up plan and communication

The discharge summary should be clear, concise, considered and polite in language. Follow up actions, whether to a GP, Specialist or allied health practitioners, should be documented with accurate information, with contact numbers, where possible. A debrief communication should take place to:

  • Make patients aware of the follow ups
  • Advise the time frame for the follow ups
  • Outline who is making the appointments
  • Inform the patient if a referral letter is needed
  • Advise if community services have already been arranged

Providing a GP with a discharge summary that satisfies these points ensures a continued high-quality of care for the patient with a seamless handover.

The advancements made to Electronic discharge summary (EDS) systems have resulted with pre-populated templates with an approved sequence, layout and format of the core elements required. These accelerates aftercare plans and eliminates possible errors caused by incomplete summaries and inaccuracies, or errors as a result of scanning or faxing paper-based discharge summaries.

To learn more about electronic discharge summaries, click here