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This is an extract from the RCP Generic Record Keeping document that relates specifically to the Discharge Summary and is included here as part o Description Implementation Project . The purpose of this document is to describe, using a matrix the rules and filters applied to the RCP DS headings in order to produce a GP DS for the Purpose Implementation Project as described in the project PID. It is important to note the following: - The basis of this work is the RCP Professional Record Keeping Standards work approved by the AoMRC and published in 2008 (http://www.rcplon - The work published by the RCP in its entirety is considered a standard and all headings MUST be included in DS's Notes - The meaning of each heading, as defined in the RCP publication, is part of the standard and must not be altered - The order of the headings is also part of the standard and must not be altered - The remit of this work is restricted to GP Summary only mmary and is included here as part of the Discharge Summary in order to produce a GP DS for the sole purpose of the DS published in 2008 (http://www.rcplondon.ac.uk/node/532) DS's ed This is a direct extract from the RCP Generic Record Keeping Documents and provides the headings for the DS (Section 4) and their descriptions Heading Sub Heading GP details GP name GP practice address GP practice code Patient details Patient surname, forename Name known as Date of birth Gender NHS Number Patient address Patient telephone number(s) Admission details Method of admission Source of admission Hospital site Responsible trust Date of admission Time of admission Discharge details Date of discharge Time of discharge Discharge method Discharge destination • type of destination • destination address • living alone Discharging consultant Discharging speciality/ department Clinical information Diagnosis at discharge Operations and procedures Reason for admission and Presenting complaints Mental capacity Advance decisions to refuse treatment and Resuscitation status Allergies Risks and warnings Clinical narrative Relevant investigations and results Relevant treatments and changes made to treatments Measures of physical ability and cognitive function Medication changes Discharge medications Medication recommendations Advice, recommendations and future plan Hospital GP Community and specialist services Information given to patient and/or authorised representative Patient’s concerns, expectations and wishes Results Awaited Person completing summary Doctor’s name Grade Specialty Doctor’s signature Date of completion of discharge record Distribution List and provides the headings for the DS (Section 4) and their descriptions Description The name of the patient's usual GP The name and address of the patient's registered GP practice Code which defines the practice of the patient's registered GP. Patient's usual address How the patient was admitted to hospital, e.g. emergency, elective, transfer, maternity. Where the patient was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment. Physical site to which the patient was admitted. The NHS hospital trust to which the patient was admitted (this may not be the same as the name of the hospital). Electronic environment only. Electronic environment only. e.g. Patient discharged on clinical advice or with clinical consent; patient discharged him/herself or was discharged by a relative or advocate. Patient died (national code). Can include private dwelling, penal establishment, care home etc (national code). Not required if patient’s own home. Yes or No. The consultant responsible for the patient at time of discharge. The speciality/department responsible for the patient at the time of discharge. Primary diagnosis, secondary diagnoses and relevant previous diagnoses, including complications and co- morbidities (e.g. for coding purposes). New and relevant previous operations and procedures, including complications and adverse events. The health problems and issues experienced by the patient resulting in their referral by a healthcare professional for hospital admission, e.g. chest pain, blackout, fall, a specific procedure, investigation or treatment. The mental capacity of the patient to make decisions about treatment etc. Example, where an Independent Mental Capacity Advocate (IMCA) is required for decisions relating to discharge destination, medical treatment, ability to consent etc. Any information given to a significant other in relation to this matter. Written documents, completed and signed when a person is legally competent, that explain a person’s medical wishes in advance, allowing someone else to make treatment decisions on his or her behalf later in the disease process. Includes Do Not Resuscitate orders. Allergies, drug allergies and adverse reactions. Significant risk of an unfavourable event occurring, patient is Hepatitis C +ve, MRSA +ve, HIV +ve etc. Any clinical alerts, risk of self neglect/aggression/exploitation by others. Very brief narrative description of the in-patient episode. Should include complications and nutritional status. The relevant investigations performed and their respective results, where present, e.g. endoscopy, CT Scan etc. It is important to highlight investigations and test results which relate to a GP action. The relevant treatments which the patient received during the inpatient stay. Can include medications given whilst an inpatient. e.g. Activity of Daily Living and cognitive function scale scores if not independent, weight/nutritional status at discharge. If admission medication stopped need to state reason. If medication started and stopped because of adverse reaction need to state reason. Can include: • medication dispensed on discharge • medication prescribed and not dispensed (e.g. patient’s own) • medications to be commenced after discharge • NOMAD/ pill dispenser being used. A medication recommendation about a drug or device allows a suggestion to be made for starting, discontinuing, changing or avoiding items in a patient’s medication record. The medication recommendation may be made to another clinician or directly to the patient. Examples include: • continue medication x and y • change dose of z after 3 weeks • consider change from medication a to med b if not effective • stop medication c and d Actions required/that will be carried out by the hospital department. To include: • action (e.g. outpatient, pending investigations and results, outstanding issues) • person responsible • appropriate date and time. Actions required by the GP. To include: • action (e.g. specific actions, pending investigations and results, outstanding issues, HRT and cervical screening) • person responsible • appropriate date and time. • suggested strategies for potential problems, e.g. telephone contact for advice Actions requested/ planned/ agreed with community services (community matron,palliative care, specialist nurse practitioner, rehab team, social services). To include: • action • person responsible • appropriate date and time. This can include: • relatives and carers • specific verbal advice and details of any discussions • written information including leaflets, letters and any other documentation. Differentiation required between information given to patients, carers and any other authorised representatives. The patient’s expressed wishes, expectations and concerns. Y/N (If Yes please specify), e.g. pathology, investigations, imaging. Only needed on paper discharge record. There are three distinct rules that apply to the DS described within this Guidance 1 Making the right fields available to the user at the Trust e 2 Completing appropriate fields at the Trust end 3. Sending the right information to the GP. 1. Making the right fields available to the user (Trust Input Screen): All headings within the standard must be present on the input side, i.e. no fields must be omitted, all must b There are three different categories of input field for the headings (see below). The order of headings given in the RCP standard is the order which MUST be used Format and wording of headings must be complied with for both technical reasons and clinical safety. 2. Completing appropriate fields at the Trust end*: Each heading will have an input field which will be in one of three categories. The categories for the input f 1. Mandatory: Must be completed, will not have a default. 2. Mandatory with default: Must be completed, even if only with a default entry. The default fields Not completed Assessed and nothing to report Assessed - see other fields Awaiting results 3. Complete if information is available: Entry into this input field only if information is available - It is * The next tab shows details the headings in each category **This combines the categories previous called Core if Present 1, optional and non core. 3. Rule for sending the right information to the GP: One rule applies. Any heading that has information entered in its input field will be sent along with the ente Where the input field is blank neither the heading nor the input filed will be sent.: Category Completion / input rule Mandatory Mandatory with Default Make entry only if information is available hat apply to the DS described within this Guidance. All must be followed: the right fields available to the user at the Trust end Completing appropriate fields at the Trust end 3. Sending the right information to the GP. user (Trust Input Screen): ust be present on the input side, i.e. no fields must be omitted, all must be presented to the user. s of input field for the headings (see below). RCP standard is the order which MUST be used ust be complied with for both technical reasons and clinical safety. ld which will be in one of three categories. The categories for the input fields are: mpleted, will not have a default. Must be completed, even if only with a default entry. The default fields will consist of such options as: hing to report s available: Entry into this input field only if information is available - It is permissible for this field to be left blank. **" ls the headings in each category ories previous called Core if Present 1, optional and non core. has information entered in its input field will be sent along with the entered information. nk neither the heading nor the input filed will be sent.: Description Outcome Input field cannot be blank. No default entry provided. This field cannot be left blank and so as a result the heading plus contents of entry field will always be sent to the GP. Input field cannot be blank. Default entry provided. The purpose of the default entry is to prevent the input field from being accidently omitted but to enable the sender purposefully to state if no information is available and why. The field cannot be left blank and so as a result the heading plus contents of entry field will always be sent to the GP. Examples of default entries would be: - Not completed - Assesses and nothing to report - Assessed and something to report - Awaiting results Only enter information if available. It is permissible for the input field under such headings to be left blank. The heading plus information in input field will only be sent to the GP if not blank. If the field is left blank then nothing relating to that heading will be sent to the GP. eft blank. **" This table details which category the individual headings within the DS fall into. For further explanation se previous tab. Complete if Mandatory with Information Heading Sub Heading Mandatory Default Available GP details GP name √ GP practice address √ GP practice code √ Patient details Patient surname, forename √ Name known as √ Date of birth √ Gender √ NHS Number √ Patient address √ Patient telephone number(s) √ Admission details Method of admission √ Source of admission √ Hospital site √ Responsible trust √ Date of admission √ Time of admission √ Discharge details Date of discharge √ Time of discharge √ Discharge method √ Discharge destination • type of destination √ • destination address √ • living alone √ Discharging consultant √ Discharging speciality/ department √ Clinical information Diagnosis at discharge √ Operations and procedures √ Reason for admission and Presenting complaints √ Mental capacity √ Advance decisions to refuse treatment and Resuscitation status √ Allergies New √ Historic √ Risks and warnings √ Clinical narrative √ Relevant investigations and results √ Relevant treatments and changes made to treatments √ Measures of physical ability and cognitive function √ Medication changes √ Discharge medications √ Medication recommendations √ Advice, recommendations and future plan Hospital √ GP √ Community and specialist services √ Information given to patient and/or authorised representative √ Patient’s concerns, expectations and wishes √ Results Awaited √ Person completing summary Doctor’s name √ Grade √ Specialty √ Doctor’s signature √ Date of completion of discharge record √ Distribution List √ all into. For further explanation see Comments If the system is able to comply If the system is able to comply Differentiation between old and new allergies is recommended. If this is not possible a complete list should be sent. If a full list of changes is not possible, free text is acceptable.
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