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Patients nominate a GP as part of their admission process. We routinely send discharge summaries to these nominated GPs. To be able to do this we need your up to date contact information on our database. If you would like to register or update your contact details in our database please call 02 9382 8811. We can provide GPs and Medical Officers information on their patients who have attended our Hospital and the Royal Hospital for Women.To access information about your patient, please send a fax to our Release of Information Team on fax number 02 9382 9172. Your fax needs to be on your clinic/Hospital/Practice letterhead. It should include: If you are not the nominated GP on the patient’s record you will also need to fax us your patient’s written consent. As patients nominated GP can change or be incorrect, we suggest you fax us your patient's written consent with all information requests as this can save you time. You can use this template for consent or your own. Requests are processed Monday to Friday during the business hours of 8.00 am – 4.30 pm. Requests received out of hours will be processed next business day. Urgent out of hours requests must be identified as urgent and will be processed by out of hours staff. For further assistance you can call our Health Information Unit on: 02 9382 3770. A discharge summary plays a crucial role in keeping patients safe after leaving a hospital. As an Advances in Patient Safety report notes, "Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care. High-quality discharge summaries are generally thought to be essential for promoting patient safety during transitions between care settings, particularly during the initial post-hospital period." While the development of electronic solutions has helped improve communication about patient information as they move from one health care setting to the next, use of these resources does not negate the importance of and a hospital's responsibility for completing a discharge summary. As a Joint Commission Journal on Quality and Patient Safety report notes, "… incomplete discharge summaries remain a common problem that may contribute to poor post-hospital outcomes." So, what should your hospital ensure is included in its discharge summary?
6 Components of a Hospital Discharge SummaryAs a For the Record report points out, The Joint Commission mandates all discharge summaries must contain six high-level components, which are also noted as requirements in the National Quality Forum's Safe Practices for Better Healthcare. The Advances in Patient Safety report referenced earlier shares these components and includes a consensus definition arrived at by two physicians and one geriatric nurse practitioner. for each. These are summarized as follows: 1. Reason for hospitalization:
2. Significant findings:Primary diagnoses. 3. Procedures and treatment provided:
4. Patient's discharge condition:Documentation that gives a sense for how the patient is doing at discharge or the patient's health status on discharge. 5. Patient and family instructions (as appropriate):
6. Attending physician's signature:A signature (electronic or physical) of the attending physician on the discharge summary. For extensive information regarding these six mandatory discharge summary elements, click here.
Additional Hospital Discharge Summary RecommendationsWhile these six components can serve as a strong foundation for what your hospital should address in its discharge summary, consider whether it would be worthwhile to include other components that can help improve patient safety. One set of standards you may want to consider came out of the Transitions of Care Consensus Conference (TOCCC), a meeting convened by the American College of Physicians, the Society of General Internal Medicine, and the Society of Hospital Medicine (SHM), with representation from the emergency medicine community. As a Journal of General Internal Medicine article notes, TOCCC proposed a minimal set of data elements that should be included in the transition record (which overlap with the components outlined above). TOCCC also recommended additional elements for an "ideal transition record." These were identified as follows:
Access to Post-Discharge SummariesIt should be mentioned that while comprehensive, accurate discharge summaries are essential to follow-up care, their availability to primary care providers is just as crucial. In a study published in The Journal of the American Board of Family Medicine, providers surveyed indicated that they only “…had a [post-discharge] summary available 0% to 40% of the time, 41.4% noted availability 41% to 80% of the time and 31.1% >80% of the time.” The study concluded that significant opportunities exist to improve the timeliness and availability of PDS through a combination of process redesign and electronic medical record utilization. To read the entire study, click here. Discharge Summary ResourcesLooking to create or update a hospital discharge summary? There's no need to reinvent the wheel. You can emulate hospital discharge summaries used by other organizations. Here are a few resources you may find helpful:
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