Discharge Summaries Practical advice

Aims Why they’re important What to include What not to include What is inappropriate transfer of work

Why discharge letter are important GP No access to hospital notes Vital for continuity of care Coding into primary care records Alteration of medications Hospital Immediately accessible on intranet Readmissions to A+E/ AMU prior to notes being retrieved Papers notes lost/ cant be found Patients Receive their own copy May show to relatives to discuss events

What to include Diagnosis During admission Medications Reviews by other specialities + their advice If abnormal results – please quantify If antibiotics used state which If COPD state baseline O2 saturations during stay Ceiling of care/ prognosis that has been discussed with patients If any ongoing referrals/ investigations reason for this Medications Any changes: if so please state reason

What not to include No medical acronyms Information not discussed with patient Any urgent task Can be 48-72h from time of discharge letter being completed before it is seen by a GP Full scan reports Normal/ Main findings

What is inappropriate transfer of work

Transfer of work Fit Notes Bloods Referrals Follow up with GP Give the patient a cyberlab form, patient can take this to drop in clinics at: WIC (fleetwood/ whitegate drive/ BVH pathology) State this has been arranged + GP to review the result Referrals Community services: IVI service, extensive care, rapid response, district nurses Nursing staff will often organise this is requested Another speciality: responsibility of hospital doctors to arrange this Consultant to consultant referral form for OP appointment Follow up with GP Ask the patient to arrange this + please state as such on the discharge letter Please advise why? Under gmc code of conduct – hospital found responsible as it is there duties to the patient Creates unnecessary work/ increased waiting times for patients + unnecesscary delay

Any questions