The Professional Record Standards Body (PRSB) has published a revised Electronic Discharge Summary Standard, to help facilitate better care for patients after hospital discharge.
Key among the changes are revisions to the information that should be entered on a patient’s care record regarding the medications used during their treatment and care. This will ensure that all the relevant information about a patient’s care, including medications, diagnosis and ongoing treatment, will be passed to the GP after discharge so that they have everything they need to provide high-quality ongoing care.
The revised e-Discharge Summary Standard was produced in two phases. The first phase of the project, completed in April 2015, developed information models for 11 key headings in the discharge summary. The second phase focused on medicines and on the validation of the previously developed information models for diagnoses, procedures, allergies and adverse reactions, as well as some administrative headings.
NHS Digital has developed technical standards so that the e-Discharge Summary can be implemented across the UK. As part of the standard NHS contract, providers are required to use PRSB headings to structure the content of the discharge summary and from October 2018 they will need to send structured and coded discharge summaries to GPs.
