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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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