Hospital discharge document standards by Dc6Od9

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									February 2011
                                     Record Keeping Audit Tool: Hospital Discharge


The aim of this tool is to facilitate audit of discharge records against the Academy of Medical Royal Colleges’ Record Keeping
Standards; developed in a project led by the Health Informatics Unit of the Royal College of Physicians and launched in October
2008 (http://www.rcplondon.ac.uk/node/402).

The development of the consensus and evidence based standards included large scale consultation with practising clinicians and
professional bodies. All the medical royal colleges approved the standards which were signed off by the Academy of Medical
Royal Colleges as fit for purpose for the medical profession.

The discharge record standards are a series of headings that should appear in discharge summaries. There are occasions when
some of these headings may not be relevant. In electronic records the information under some of the headings will be completed
automatically.

The recommended parameters for an audit of discharge records are:
* Retrospective data collection
* This tool is for clinical governance staff; audit teams; junior doctors and consultants
* An audit of patients who have recently been discharged

The audit tool is designed to help identify areas where practice could be improved - this may include changing personal
behaviours and also talking to relevant people in the Trust to implement standardised procedures etc. The rule is ‘if it is not
recorded it has not been done’.

Instructions for using this audit tool:


                            Step 1. Randomly select 10 sets of notes of recently discharged patients


                            Step 2. Look through each set of notes and complete a separate template (eg.
                                   Record 1, Record 2, etc) for each one of the sets of notes


                                     Step 3. Complete each template to indicate the following:
                                          * Is each Heading / Sub-Heading Present?
                                              (Yes / No options are available to tick)
                                          * Is the Appropriate Information Present under each Heading / Sub-
                                            heading? (Yes / No / Not Applicable options are available to tick)
                                     Clicking on an       button will take you to a description of what should
                                            appear under that heading.



                            If the information under the Heading is illegible please do make sure that you tick
                            No and add a comment on this

                            If you choose to tick the N/A option please add a comment that gives the reason
                            why it was not applicable. It is good practice to decide what is not N/A before you
                            start the audit

                            Step 4. Please provide us any comments or feedback on this audit tool. This can
                                    be done using the Feedback system provided


                     This audit tool should be used in conjunction with the RCP standards for record keeping
                                              http://www.rcplondon.ac.uk/node/402
This workbook includes the following tabs:

* Record 1: A template to be completed for your 1st record / set of notes
* Rec 2:    A template to be completed for your 2nd record / set of notes
* Rec 3:    A template to be completed for your 3rd record / set of notes
* Rec 4:    A template to be completed for your 4th record / set of notes
* Rec 5:    A template to be completed for your 5th record / set of notes
* Rec 6:    A template to be completed for your 6th record / set of notes
* Rec 7:    A template to be completed for your 7th record / set of notes
* Rec 8:    A template to be completed for your 8th record / set of notes
* Rec 9:    A template to be completed for your 9th record / set of notes
* Rec 10: A template to be completed for your 10th record / set of notes
* Summary 1: A summary of the totals and percentages calculated based on the number of templates completed
* Summary 2: This is a summarised version of the information in Summary 1
* Comments: This contains all comments added in relation to all the templates completed
* Headings Definitions: Contains definitions of the clinical information to be recorded under each heading

                                                                                                             February 2011
                                                                    Hospital Discharge Audit Tool 1
                                                                               Heading             Information Appropriate for Heading
                           Heading/Sub-Heading                                 Present                              Present                                 Comments
                                                                                                        If information is illegible please
                                                                                                        tick No and add a comment                       Please comment IF:
                                                                                                           If you tick N/A please add a         Information is illegible and you have
                                                                                                                   comment                           recorded it as not present
                                                                                                                                                        You tick the N/A option
                                                                         Yes             No            Yes           No            N/A

                                                                                 GP & PATIENT DETAILS

1         GP Details (e.g. GP Name, Practice Address)

2         Patient Surname, Forename

3         Date of Birth

4         Gender

5         Patient NHS Number

6         Patient Address

7         Patient Telephone Number(s)

          GP & PATIENT DETAILS - Total                                          0             7              0              7             0

                                                                                    ADMISSION DETAILS

8         Method of Admission

9         Source of admission

10        Hospital Site

11        Responsible Trust

12        Date of Admission

13        Time of Admission

          ADMISSION DETAILS - Total                                             0             6              0              6             0

                                                                                    DISCHARGE DETAILS

14        Date of Discharge

15        Time of discharge

16        Discharge method

          Discharge destination

17        - type of destination / destination address

18        - living alone

19        Discharging Consultant

20        Discharging Speciality/Department

          DISCHARGE DETAILS - Total                                             0             7              0              7             0

                                                                                CLINICAL INFORMATION

21        Diagnosis at Discharge

22        Operations and Procedures

23        Reason for Admission and Presenting Complaints
          Relevant Legal Information (incl. Mental Capacity &
24        Advance Decisions)

25        Allergies

26        Risks and Warnings

27        Clinical Narrative

28        Relevant Investigations and Results

29        Relevant treatments and changes made to treatments

30        Measures of Physical Ability and Cognitive Function

31        Medication Changes

32        Discharge Medications

33        Medication recommendations

          CLINICAL INFORMATION - Total                                          0             13             0            13              0

                                                                    ADVICE, RECOMMENDATIONS AND FUTURE PLAN

          Hospital

     34               A) Action (e.g. outstanding investigations)
                                                              Hospital Discharge Audit Tool 1
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                              Present                                 Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                       Please comment IF:
                                                                                                    If you tick N/A please add a         Information is illegible and you have
                                                                                                            comment                           recorded it as not present
                                                                                                                                                 You tick the N/A option
                                                                  Yes             No            Yes           No            N/A

35            B) Person Responsible                                       GP & PATIENT DETAILS

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

46 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13             0            13              0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5              0              5             0

               Hospital Admission Audit - TOTAL                          0             51             0            51              0

                 Hospital Admission Audit - %                       0.0%          113.3%           0.0%       113.3%           0.0%                                 February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

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2   2

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2   2

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2   2

2   2
                                                                    Hospital Discharge Audit Tool 2
                                                                               Heading             Information Appropriate for Heading
                           Heading/Sub-Heading                                 Present                              Present                                 Comments
                                                                                                        If information is illegible please
                                                                                                        tick No and add a comment                       Please comment IF:
                                                                                                           If you tick N/A please add a         Information is illegible and you have
                                                                                                                   comment                           recorded it as not present
                                                                                                                                                        You tick the N/A option
                                                                         Yes             No            Yes           No            N/A

                                                                                 GP & PATIENT DETAILS

1         GP Details (e.g. GP Name, Practice Address)

2         Patient Surname, Forename

3         Date of Birth

4         Gender

5         Patient NHS Number

6         Patient Address

7         Patient Telephone Number(s)

          GP & PATIENT DETAILS - Total                                          0             7              0              7             0

                                                                                    ADMISSION DETAILS

8         Method of Admission

9         Source of admission

10        Hospital Site

11        Responsible Trust

12        Date of Admission

13        Time of Admission

          ADMISSION DETAILS - Total                                             0             6              0              6             0

                                                                                    DISCHARGE DETAILS

14        Date of Discharge

15        Time of discharge

16        Discharge method

          Discharge destination

17        - type of destination / destination address

18        - living alone

19        Discharging Consultant

20        Discharging Speciality/Department

          DISCHARGE DETAILS - Total                                             0             7              0              7             0

                                                                                CLINICAL INFORMATION

21        Diagnosis at Discharge

22        Operations and Procedures

23        Reason for Admission and Presenting Complaints
          Relevant Legal Information (incl. Mental Capacity &
24        Advance Decisions)

25        Allergies

26        Risks and Warnings

27        Clinical Narrative

28        Relevant Investigations and Results

29        Relevant treatments and changes made to treatments

30        Measures of Physical Ability and Cognitive Function

31        Medication Changes

32        Discharge Medications

33        Medication recommendations

          CLINICAL INFORMATION - Total                                          0             13             0            13              0

                                                                    ADVICE, RECOMMENDATIONS AND FUTURE PLAN

          Hospital

     34               A) Action (e.g. outstanding investigations)
                                                              Hospital Discharge Audit Tool 2
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                              Present                                 Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                       Please comment IF:
                                                                                                    If you tick N/A please add a         Information is illegible and you have
                                                                                                            comment                           recorded it as not present
                                                                                                                                                 You tick the N/A option
                                                                  Yes             No            Yes           No            N/A

35            B) Person Responsible                                       GP & PATIENT DETAILS

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

46 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13             0            13              0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5              0              5             0

               Hospital Admission Audit - TOTAL                          0             51             0            51              0

                 Hospital Admission Audit - %                       0.0%          113.3%           0.0%       113.3%           0.0%                                 February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

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2   2

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2   2

2   2

2   2

2   2

2   2

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2   2

2   2

2   2

2   2

2   2
                                                                    Hospital Discharge Audit Tool 3
                                                                               Heading             Information Appropriate for Heading
                           Heading/Sub-Heading                                 Present                              Present                                 Comments
                                                                                                        If information is illegible please
                                                                                                        tick No and add a comment                       Please comment IF:
                                                                                                           If you tick N/A please add a         Information is illegible and you have
                                                                                                                   comment                           recorded it as not present
                                                                                                                                                        You tick the N/A option
                                                                         Yes             No            Yes           No            N/A

                                                                                 GP & PATIENT DETAILS

1         GP Details (e.g. GP Name, Practice Address)

2         Patient Surname, Forename

3         Date of Birth

4         Gender

5         Patient NHS Number

6         Patient Address

7         Patient Telephone Number(s)

          GP & PATIENT DETAILS - Total                                          0             7              0              7             0

                                                                                    ADMISSION DETAILS

8         Method of Admission

9         Source of admission

10        Hospital Site

11        Responsible Trust

12        Date of Admission

13        Time of Admission

          ADMISSION DETAILS - Total                                             0             6              0              6             0

                                                                                    DISCHARGE DETAILS

14        Date of Discharge

15        Time of discharge

16        Discharge method

          Discharge destination

17        - type of destination / destination address

18        - living alone

19        Discharging Consultant

20        Discharging Speciality/Department

          DISCHARGE DETAILS - Total                                             0             7              0              7             0

                                                                                CLINICAL INFORMATION

21        Diagnosis at Discharge

22        Operations and Procedures

23        Reason for Admission and Presenting Complaints
          Relevant Legal Information (incl. Mental Capacity &
24        Advance Decisions)

25        Allergies

26        Risks and Warnings

27        Clinical Narrative

28        Relevant Investigations and Results

29        Relevant treatments and changes made to treatments

30        Measures of Physical Ability and Cognitive Function

31        Medication Changes

32        Discharge Medications

33        Medication recommendations

          CLINICAL INFORMATION - Total                                          0             13             0            13              0

                                                                    ADVICE, RECOMMENDATIONS AND FUTURE PLAN

          Hospital

     34               A) Action (e.g. outstanding investigations)
                                                              Hospital Discharge Audit Tool 3
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                              Present                                 Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                       Please comment IF:
                                                                                                    If you tick N/A please add a         Information is illegible and you have
                                                                                                            comment                           recorded it as not present
                                                                                                                                                 You tick the N/A option
                                                                  Yes             No            Yes           No            N/A

35            B) Person Responsible                                       GP & PATIENT DETAILS

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

45 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13             0            13              0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5              0              5             0

               Hospital Admission Audit - TOTAL                          0             51             0            51              0

                 Hospital Admission Audit - %                       0.0%          113.3%           0.0%       113.3%           0.0%                                 February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

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2   2
                                                                    Hospital Discharge Audit Tool 4
                                                                               Heading             Information Appropriate for Heading
                           Heading/Sub-Heading                                 Present                              Present                                 Comments
                                                                                                        If information is illegible please
                                                                                                        tick No and add a comment                       Please comment IF:
                                                                                                           If you tick N/A please add a         Information is illegible and you have
                                                                                                                   comment                           recorded it as not present
                                                                                                                                                        You tick the N/A option
                                                                         Yes             No            Yes           No            N/A

                                                                                 GP & PATIENT DETAILS

1         GP Details (e.g. GP Name, Practice Address)

2         Patient Surname, Forename

3         Date of Birth

4         Gender

5         Patient NHS Number

6         Patient Address

7         Patient Telephone Number(s)

          GP & PATIENT DETAILS - Total                                          0             7              0              7             0

                                                                                    ADMISSION DETAILS

8         Method of Admission

9         Source of admission

10        Hospital Site

11        Responsible Trust

12        Date of Admission

13        Time of Admission

          ADMISSION DETAILS - Total                                             0             6              0              6             0

                                                                                    DISCHARGE DETAILS

14        Date of Discharge

15        Time of discharge

16        Discharge method

          Discharge destination

17        - type of destination / destination address

18        - living alone

19        Discharging Consultant

20        Discharging Speciality/Department

          DISCHARGE DETAILS - Total                                             0             7              0              7             0

                                                                                CLINICAL INFORMATION

21        Diagnosis at Discharge

22        Operations and Procedures

23        Reason for Admission and Presenting Complaints
          Relevant Legal Information (incl. Mental Capacity &
24        Advance Decisions)

25        Allergies

26        Risks and Warnings

27        Clinical Narrative

28        Relevant Investigations and Results

29        Relevant treatments and changes made to treatments

30        Measures of Physical Ability and Cognitive Function

31        Medication Changes

32        Discharge Medications

33        Medication recommendations

          CLINICAL INFORMATION - Total                                          0             13             0            13              0

                                                                    ADVICE, RECOMMENDATIONS AND FUTURE PLAN

          Hospital

     34               A) Action (e.g. outstanding investigations)
                                                              Hospital Discharge Audit Tool 4
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                              Present                                 Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                       Please comment IF:
                                                                                                    If you tick N/A please add a         Information is illegible and you have
                                                                                                            comment                           recorded it as not present
                                                                                                                                                 You tick the N/A option
                                                                  Yes             No            Yes           No            N/A

35            B) Person Responsible                                       GP & PATIENT DETAILS

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

46 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13             0            13              0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5              0              5             0

               Hospital Admission Audit - TOTAL                          0             51             0            51              0

                 Hospital Admission Audit - %                       0.0%          113.3%           0.0%       113.3%           0.0%                                 February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

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                                                                    Hospital Discharge Audit Tool 5
                                                                               Heading             Information Appropriate for Heading
                           Heading/Sub-Heading                                 Present                              Present                                 Comments
                                                                                                        If information is illegible please
                                                                                                        tick No and add a comment                       Please comment IF:
                                                                                                           If you tick N/A please add a         Information is illegible and you have
                                                                                                                   comment                           recorded it as not present
                                                                                                                                                        You tick the N/A option
                                                                         Yes             No            Yes           No            N/A

                                                                                 GP & PATIENT DETAILS

1         GP Details (e.g. GP Name, Practice Address)

2         Patient Surname, Forename

3         Date of Birth

4         Gender

5         Patient NHS Number

6         Patient Address

7         Patient Telephone Number(s)

          GP & PATIENT DETAILS - Total                                          0             7              0              7             0

                                                                                    ADMISSION DETAILS

8         Method of Admission

9         Source of admission

10        Hospital Site

11        Responsible Trust

12        Date of Admission

13        Time of Admission

          ADMISSION DETAILS - Total                                             0             6              0              6             0

                                                                                    DISCHARGE DETAILS

14        Date of Discharge

15        Time of discharge

16        Discharge method

          Discharge destination

17        - type of destination / destination address

18        - living alone

19        Discharging Consultant

20        Discharging Speciality/Department

          DISCHARGE DETAILS - Total                                             0             7              0              7             0

                                                                                CLINICAL INFORMATION

21        Diagnosis at Discharge

22        Operations and Procedures

23        Reason for Admission and Presenting Complaints
          Relevant Legal Information (incl. Mental Capacity &
24        Advance Decisions)

25        Allergies

26        Risks and Warnings

27        Clinical Narrative

28        Relevant Investigations and Results

29        Relevant treatments and changes made to treatments

30        Measures of Physical Ability and Cognitive Function

31        Medication Changes

32        Discharge Medications

33        Medication recommendations

          CLINICAL INFORMATION - Total                                          0             13             0            13              0

                                                                    ADVICE, RECOMMENDATIONS AND FUTURE PLAN

          Hospital

     34               A) Action (e.g. outstanding investigations)
                                                              Hospital Discharge Audit Tool 5
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                              Present                                 Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                       Please comment IF:
                                                                                                    If you tick N/A please add a         Information is illegible and you have
                                                                                                            comment                           recorded it as not present
                                                                                                                                                 You tick the N/A option
                                                                  Yes             No            Yes           No            N/A

35            B) Person Responsible                                       GP & PATIENT DETAILS

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

46 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13             0            13              0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5              0              5             0

               Hospital Admission Audit - TOTAL                          0             51             0            51              0

                 Hospital Admission Audit - %                       0.0%          113.3%           0.0%       113.3%           0.0%                                 February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

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2   2

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2   2

2   2

2   2
                                                                    Hospital Discharge Audit Tool 6
                                                                               Heading             Information Appropriate for Heading
                           Heading/Sub-Heading                                 Present                              Present                                 Comments
                                                                                                        If information is illegible please
                                                                                                        tick No and add a comment                       Please comment IF:
                                                                                                           If you tick N/A please add a         Information is illegible and you have
                                                                                                                   comment                           recorded it as not present
                                                                                                                                                        You tick the N/A option
                                                                         Yes             No            Yes           No            N/A

                                                                                 GP & PATIENT DETAILS

1         GP Details (e.g. GP Name, Practice Address)

2         Patient Surname, Forename

3         Date of Birth

4         Gender

5         Patient NHS Number

6         Patient Address

7         Patient Telephone Number(s)

          GP & PATIENT DETAILS - Total                                          0             7              0              7             0

                                                                                    ADMISSION DETAILS

8         Method of Admission

9         Source of admission

10        Hospital Site

11        Responsible Trust

12        Date of Admission

13        Time of Admission

          ADMISSION DETAILS - Total                                             0             6              0              6             0

                                                                                    DISCHARGE DETAILS

14        Date of Discharge

15        Time of discharge

16        Discharge method

          Discharge destination

17        - type of destination / destination address

18        - living alone

19        Discharging Consultant

20        Discharging Speciality/Department

          DISCHARGE DETAILS - Total                                             0             7              0              7             0

                                                                                CLINICAL INFORMATION

21        Diagnosis at Discharge

22        Operations and Procedures

23        Reason for Admission and Presenting Complaints
          Relevant Legal Information (incl. Mental Capacity &
24        Advance Decisions)

25        Allergies

26        Risks and Warnings

27        Clinical Narrative

28        Relevant Investigations and Results

29        Relevant treatments and changes made to treatments

30        Measures of Physical Ability and Cognitive Function

31        Medication Changes

32        Discharge Medications

33        Medication recommendations

          CLINICAL INFORMATION - Total                                          0             13             0            13              0

                                                                    ADVICE, RECOMMENDATIONS AND FUTURE PLAN

          Hospital

     34               A) Action (e.g. outstanding investigations)
                                                              Hospital Discharge Audit Tool 6
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                              Present                                 Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                       Please comment IF:
                                                                                                    If you tick N/A please add a         Information is illegible and you have
                                                                                                            comment                           recorded it as not present
                                                                                                                                                 You tick the N/A option
                                                                  Yes             No            Yes           No            N/A

35            B) Person Responsible                                       GP & PATIENT DETAILS

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

46 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13             0            13              0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5              0              5             0

               Hospital Admission Audit - TOTAL                          0             51             0            51              0

                 Hospital Admission Audit - %                       0.0%          113.3%           0.0%       113.3%           0.0%                                 February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2



2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2
2   2

2   2



2   2

2   2

2   2

2   2



2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2
                                                                    Hospital Discharge Audit Tool 7
                                                                               Heading             Information Appropriate for Heading
                           Heading/Sub-Heading                                 Present                              Present                                 Comments
                                                                                                        If information is illegible please
                                                                                                        tick No and add a comment                       Please comment IF:
                                                                                                           If you tick N/A please add a         Information is illegible and you have
                                                                                                                   comment                           recorded it as not present
                                                                                                                                                        You tick the N/A option
                                                                         Yes             No            Yes           No            N/A

                                                                                 GP & PATIENT DETAILS

1         GP Details (e.g. GP Name, Practice Address)

2         Patient Surname, Forename

3         Date of Birth

4         Gender

5         Patient NHS Number

6         Patient Address

7         Patient Telephone Number(s)

          GP & PATIENT DETAILS - Total                                          0             7              0              7             0

                                                                                    ADMISSION DETAILS

8         Method of Admission

9         Source of admission

10        Hospital Site

11        Responsible Trust

12        Date of Admission

13        Time of Admission

          ADMISSION DETAILS - Total                                             0             6              0              6             0

                                                                                    DISCHARGE DETAILS

14        Date of Discharge

15        Time of discharge

16        Discharge method

          Discharge destination

17        - type of destination / destination address

18        - living alone

19        Discharging Consultant

20        Discharging Speciality/Department

          DISCHARGE DETAILS - Total                                             0             7              0              7             0

                                                                                CLINICAL INFORMATION

21        Diagnosis at Discharge

22        Operations and Procedures

23        Reason for Admission and Presenting Complaints
          Relevant Legal Information (incl. Mental Capacity &
24        Advance Decisions)

25        Allergies

26        Risks and Warnings

27        Clinical Narrative

28        Relevant Investigations and Results

29        Relevant treatments and changes made to treatments

30        Measures of Physical Ability and Cognitive Function

31        Medication Changes

32        Discharge Medications

33        Medication recommendations

          CLINICAL INFORMATION - Total                                          0             13             0            13              0

                                                                    ADVICE, RECOMMENDATIONS AND FUTURE PLAN

          Hospital

     34               A) Action (e.g. outstanding investigations)
                                                              Hospital Discharge Audit Tool 7
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                              Present                                 Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                       Please comment IF:
                                                                                                    If you tick N/A please add a         Information is illegible and you have
                                                                                                            comment                           recorded it as not present
                                                                                                                                                 You tick the N/A option
                                                                  Yes             No            Yes           No            N/A

35            B) Person Responsible                                       GP & PATIENT DETAILS

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

46 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13             0            13              0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5              0              5             0

               Hospital Admission Audit - TOTAL                          0             51             0            51              0

                 Hospital Admission Audit - %                       0.0%          113.3%           0.0%       113.3%           0.0%                                 February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2



2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2
2   2

2   2



2   2

2   2

2   2

2   2



2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2
                                                                    Hospital Discharge Audit Tool 8
                                                                               Heading             Information Appropriate for Heading
                           Heading/Sub-Heading                                 Present                              Present                                 Comments
                                                                                                        If information is illegible please
                                                                                                        tick No and add a comment                       Please comment IF:
                                                                                                           If you tick N/A please add a         Information is illegible and you have
                                                                                                                   comment                           recorded it as not present
                                                                                                                                                        You tick the N/A option
                                                                         Yes             No            Yes           No            N/A

                                                                                 GP & PATIENT DETAILS

1         GP Details (e.g. GP Name, Practice Address)

2         Patient Surname, Forename

3         Date of Birth

4         Gender

5         Patient NHS Number

6         Patient Address

7         Patient Telephone Number(s)

          GP & PATIENT DETAILS - Total                                          0             7              0              7             0

                                                                                    ADMISSION DETAILS

8         Method of Admission

9         Source of admission

10        Hospital Site

11        Responsible Trust

12        Date of Admission

13        Time of Admission

          ADMISSION DETAILS - Total                                             0             6              0              6             0

                                                                                    DISCHARGE DETAILS

14        Date of Discharge

15        Time of discharge

16        Discharge method

          Discharge destination

17        - type of destination / destination address

18        - living alone

19        Discharging Consultant

20        Discharging Speciality/Department

          DISCHARGE DETAILS - Total                                             0             7              0              7             0

                                                                                CLINICAL INFORMATION

21        Diagnosis at Discharge

22        Operations and Procedures

23        Reason for Admission and Presenting Complaints
          Relevant Legal Information (incl. Mental Capacity &
24        Advance Decisions)

25        Allergies

26        Risks and Warnings

27        Clinical Narrative

28        Relevant Investigations and Results

29        Relevant treatments and changes made to treatments

30        Measures of Physical Ability and Cognitive Function

31        Medication Changes

32        Discharge Medications

33        Medication recommendations

          CLINICAL INFORMATION - Total                                          0             13             0            13              0

                                                                    ADVICE, RECOMMENDATIONS AND FUTURE PLAN

          Hospital

     34               A) Action (e.g. outstanding investigations)
                                                              Hospital Discharge Audit Tool 8
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                              Present                                 Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                       Please comment IF:
                                                                                                    If you tick N/A please add a         Information is illegible and you have
                                                                                                            comment                           recorded it as not present
                                                                                                                                                 You tick the N/A option
                                                                  Yes             No            Yes           No            N/A

35            B) Person Responsible                                       GP & PATIENT DETAILS

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

46 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13             0            13              0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5              0              5             0

               Hospital Admission Audit - TOTAL                          0             51             0            51              0

                 Hospital Admission Audit - %                       0.0%          113.3%           0.0%       113.3%           0.0%                                 February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2



2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2
2   2

2   2



2   2

2   2

2   2

2   2



2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2
                                                           Hospital Discharge Audit Tool 9
                                                                      Heading             Information Appropriate for Heading
                      Heading/Sub-Heading                             Present                              Present                                 Comments
                                                                                               If information is illegible please
                                                                                               tick No and add a comment                       Please comment IF:
                                                                                                  If you tick N/A please add a         Information is illegible and you have
                                                                                                          comment                           recorded it as not present
                                                                                                                                               You tick the N/A option
                                                                Yes             No            Yes           No            N/A

                                                                        GP & PATIENT DETAILS

1    GP Details (e.g. GP Name, Practice Address)

2    Patient Surname, Forename

3    Date of Birth

4    Gender

5    Patient NHS Number

6    Patient Address

7    Patient Telephone Number(s)

     GP & PATIENT DETAILS - Total                                      0             7              0              7             0

                                                                           ADMISSION DETAILS

8    Method of Admission

9    Source of admission

10   Hospital Site

11   Responsible Trust

12   Date of Admission

13   Time of Admission

     ADMISSION DETAILS - Total                                         0             6              1              5             0

                                                                           DISCHARGE DETAILS

14   Date of Discharge

15   Time of discharge

16   Discharge method

     Discharge destination

17   - type of destination / destination address

18   - living alone

19   Discharging Consultant

20   Discharging Speciality/Department

     DISCHARGE DETAILS - Total                                         0             7              0              7             0

                                                                       CLINICAL INFORMATION

21   Diagnosis at Discharge

22   Operations and Procedures

23   Reason for Admission and Presenting Complaints
     Relevant Legal Information (incl. Mental Capacity &
24   Advance Decisions)

25   Allergies

26   Risks and Warnings

27   Clinical Narrative

28   Relevant Investigations and Results

29   Relevant treatments and changes made to treatments

30   Measures of Physical Ability and Cognitive Function

31   Medication Changes

32   Discharge Medications

33   Medication recommendations

     CLINICAL INFORMATION - Total                                      0             13             0            13              0

                                                           ADVICE, RECOMMENDATIONS AND FUTURE PLAN

     Hospital
                                                              Hospital Discharge Audit Tool 9
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                              Present                                 Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                       Please comment IF:
                                                                                                    If you tick N/A please add a         Information is illegible and you have
                                                                                                            comment                           recorded it as not present
                                                                                                                                                 You tick the N/A option
                                                                  Yes             No            Yes           No            N/A

34            A) Action (e.g. outstanding investigations)                 GP & PATIENT DETAILS

35            B) Person Responsible

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

46 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13             0            13              0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5              0              5             0

               Hospital Admission Audit - TOTAL                          0             51             1            50              0

                 Hospital Admission Audit - %                       0.0%          113.3%           2.2%       111.1%           0.0%                                 February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   1

2   2

2   2




2   2

2   2

2   2



2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2
2   2

2   2

2   2



2   2

2   2

2   2

2   2



2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2
                                                           Hospital Discharge Audit Tool 10
                                                                      Heading             Information Appropriate for Heading
                      Heading/Sub-Heading                             Present                            Present                                       Comments
                                                                                               If information is illegible please
                                                                                               tick No and add a comment                           Please comment IF:
                                                                                                     If you tick N/A please add a          Information is illegible and you have
                                                                                                             comment                            recorded it as not present
                                                                                                                                                   You tick the N/A option
                                                                Yes             No              Yes            No           N/A

                                                                        GP & PATIENT DETAILS

1    GP Details (e.g. GP Name, Practice Address)

2    Patient Surname, Forename

3    Date of Birth

4    Gender

5    Patient NHS Number

6    Patient Address

7    Patient Telephone Number(s)

     GP & PATIENT DETAILS - Total                                      0             7                  0             7              0

                                                                           ADMISSION DETAILS

8    Method of Admission

9    Source of admission

10   Hospital Site

11   Responsible Trust

12   Date of Admission

13   Time of Admission

     ADMISSION DETAILS - Total                                         0             6                  0             6              0

                                                                           DISCHARGE DETAILS

14   Date of Discharge

15   Time of discharge

16   Discharge method

     Discharge destination

17   - type of destination / destination address

18   - living alone

19   Discharging Consultant

20   Discharging Speciality/Department

     DISCHARGE DETAILS - Total                                         0             7                  0             7              0

                                                                       CLINICAL INFORMATION

21   Diagnosis at Discharge

22   Operations and Procedures

23   Reason for Admission and Presenting Complaints
     Relevant Legal Information (incl. Mental Capacity &
24   Advance Decisions)

25   Allergies

26   Risks and Warnings

27   Clinical Narrative

28   Relevant Investigations and Results

29   Relevant treatments and changes made to treatments

30   Measures of Physical Ability and Cognitive Function

31   Medication Changes

32   Discharge Medications

33   Medication recommendations

     CLINICAL INFORMATION - Total                                      0             13                 0           13               0

                                                           ADVICE, RECOMMENDATIONS AND FUTURE PLAN

     Hospital
                                                              Hospital Discharge Audit Tool 10
                                                                        Heading             Information Appropriate for Heading
                 Heading/Sub-Heading                                    Present                            Present                                       Comments
                                                                                                 If information is illegible please
                                                                                                 tick No and add a comment                           Please comment IF:
                                                                                                       If you tick N/A please add a          Information is illegible and you have
                                                                                                               comment                            recorded it as not present
                                                                                                                                                     You tick the N/A option
                                                                  Yes             No              Yes            No           N/A

34            A) Action (e.g. outstanding investigations)                 GP & PATIENT DETAILS

35            B) Person Responsible

36            C) Appropriate Date and Time

     GP

37            A) Action (required by GP)

38            B) Person Responsible

39            C) Appropriate Date and Time

40            D) Suggested Strategies

     Community and Specialist Services

41            A) Actions required / planned / agreed

42            B) Person Responsible

43          C) Appropriate Date and Time
   Information given to Patient and / or Authorised
44 Representative

45 Patient’s Concerns, Expectations and Wishes

46 Results Awaited

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                     0             13                 0           13               0

                                                                   PERSON COMPLETING SUMMARY

47            A) Doctor’s / Health care professional’s name

48            B) Grade / Designation

49            C) Signature

50            D) Date Discharge Record Completed

51 Distribution list

     PERSON COMPLETING SUMMARY - Total                                   0             5                  0             5              0

               Hospital Admission Audit - TOTAL                          0             51                 0           51               0

                 Hospital Admission Audit - %                       0.0%          113.3%            0.0%         113.3%           0.0%                                  February 2011
2   2

2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2



2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2

2   2
2   2

2   2

2   2



2   2

2   2

2   2

2   2



2   2

2   2

2   2

2   2

2   2

2   2




2   2

2   2

2   2

2   2

2   2
                                    Hospital Discharge Audit Tool - Summary 1
                                                                                    Heading        Information Appropriate for Heading
                           Heading/Sub-Heading                                      Present                      Present
                                                                             Yes              No       Yes         No           N/A

                                                           GP & PATIENT DETAILS

1    GP Details (e.g. GP Name, Practice Address)                                0             0        0           0            0

2    Patient Surname, Forename                                                  0             0        0           0            0

3    Date of Birth                                                              0             0        0           0            0

4    Gender                                                                     0             0        0           0            0

5    Patient NHS Number                                                         0             0        0           0            0

6    Patient Address                                                            0             0        0           0            0

7    Patient Telephone Number(s)                                                0             0        0           0            0

     GP & PATIENT DETAILS - Total                                               0             0        0            0           0

     GP & PATIENT DETAILS - Overall %                                      #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!     #DIV/0!

                                                            ADMISSION DETAILS

8    Method of Admission                                                        0             0        0            0           0

9    Source of admission                                                        0             0        0            0           0

10   Hospital Site                                                              0             0        0            0           0

11   Responsible Trust                                                          0             0        0            0           0

12   Date of Admission                                                          0             0        0            0           0

13   Time of Admission                                                          0             0        0            0           0

     ADMISSION DETAILS - Total                                                  0             0        0            0           0

     ADMISSION DETAILS - Overall %                                         #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!     #DIV/0!

                                                            DISCHARGE DETAILS

14   Date of Discharge                                                          0             0        0            0           0

15   Time of discharge                                                          0             0        0            0           0

16   Discharge method                                                           0             0        0            0           0

     Discharge destination

17   - type of destination / destination address                                0             0        0            0           0

18   - living alone                                                             0             0        0            0           0

19   Discharging Consultant                                                     0             0        0            0           0

20   Discharging Speciality/Department                                          0             0        0            0           0

     DISCHARGE DETAILS - Total                                                  0             0        0            0           0

     DISCHARGE DETAILS - Overall %                                         #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!     #DIV/0!

                                                           CLINICAL INFORMATION

21   Diagnosis at Discharge                                                     0             0        0            0           0

22   Operations and Procedures                                                  0             0        0            0           0

23   Reason for Admission and Presenting Complaints                             0             0        0            0           0
     Relevant Legal Information (incl. Mental Capacity & Advance
24   Decisions)                                                                 0             0        0            0           0

25   Allergies                                                                  0             0        0            0           0

26   Risks and Warnings                                                         0             0        0            0           0

27   Clinical Narrative                                                         0             0        0            0           0

28   Relevant Investigations and Results                                        0             0        0            0           0

29   Relevant treatments and changes made to treatments                         0             0        0            0           0

30   Measures of Physical Ability and Cognitive Function                        0             0        0            0           0

31   Medication Changes                                                         0             0        0            0           0

32   Discharge Medications                                                      0             0        0            0           0

33   Medication recommendations                                                 0             0        0            0           0

     CLINICAL INFORMATION - Total                                               0             0        0            0           0

     CLINICAL INFORMATION - Overall %                                      #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!     #DIV/0!
                                      Hospital Discharge Audit Tool - Summary 1
                                                                               Heading        Information Appropriate for Heading
                          Heading/Sub-Heading                                  Present                      Present
                                                                         Yes             No       Yes         No           N/A

                                                          GP & PATIENT DETAILS
                                              ADVICE, RECOMMENDATIONS AND FUTURE PLAN

     Hospital

34              A) Action (e.g. outstanding investigations)               0              0        0            0             0

35              B) Person Responsible                                     0              0        0            0             0

36              C) Appropriate Date and Time                              0              0        0            0             0

     GP

37              A) Action (required by GP)                                0              0        0            0             0

38              B) Person Responsible                                     0              0        0            0             0

39              C) Appropriate Date and Time                              0              0        0            0             0

40              D) Suggested Strategies                                   0              0        0            0             0

     Community and Specialist Services

41              A) Actions required / planned / agreed                    0              0        0            0             0

42              B) Person Responsible                                     0              0        0            0             0

43              C) Appropriate Date and Time                              0              0        0            0             0

44 Information given to Patient and / or Authorised Representative        0              0        0            0             0

45 Patient’s Concerns, Expectations and Wishes                            0              0        0            0             0

46 Results Awaited                                                        0              0        0            0             0

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                      0              0        0            0             0

     ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Overall %                #DIV/0!     #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

                                                      PERSON COMPLETING SUMMARY

47              A) Doctor’s / Health care professional’s name             0              0        0            0             0

48              B) Grade / Designation                                    0              0        0            0             0

49              C) Signature                                              0              0        0            0             0

50              D) Date Discharge Record Completed                        0              0        0            0             0

51 Distribution list                                                      0              0        0            0             0

     PERSON COMPLETING SUMMARY - Total                                    0              0        0            0             0

     PERSON COMPLETING SUMMARY - Overall %                              #DIV/0!     #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

                HOSPITAL ADMISSION AUDIT - TOTAL                          0              0        0            0             0

     TOTAL - Average % score of all records                             #DIV/0!     #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

     TOTAL - % score of all entries                                      #N/A        #N/A       #N/A         #N/A          #N/A
                                                                                                                      February 2011




     The 'Average % score of all records' is calculated in the following way:
     TOTAL % for tab 'Record 1' + TOTAL % for tab 'Record 2'… / Total number of Record tabs completed

     The '% score of all entries' is calculated in the following way:
     TOTAL % for this 'Summary' tab / appropriate denominator for the number of Record tabs completed
                                 Hospital Discharge Audit Tool - Summary 2                                                         This is a summarised version of the information on tab
                                                                            Heading        Information Appropriate for Heading     'Summary 1'.
                    Heading/Sub-Heading                                     Present                     Present                    To see the full information please go to tab 'Summary
                                                                     Yes              No       Yes         No           N/A        1'.

                                                   GP & PATIENT DETAILS

GP & PATIENT DETAILS - Total                                            0             0        0            0             0

GP & PATIENT DETAILS - Overall %                                   #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

                                                    ADMISSION DETAILS

ADMISSION DETAILS - Total                                               0             0        0            0             0

ADMISSION DETAILS - Overall %                                      #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

                                                    DISCHARGE DETAILS

DISCHARGE DETAILS - Total                                               0             0        0            0             0

DISCHARGE DETAILS - Overall %                                      #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

                                                  CLINICAL INFORMATION

CLINICAL INFORMATION - Total                                            0             0        0            0             0

CLINICAL INFORMATION - Overall %                                   #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

                                         ADVICE, RECOMMENDATIONS AND FUTURE PLAN

ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Total                         0             0        0            0             0

ADVICE, RECOMMENDATIONS AND FUTURE PLAN - Overall %                #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

                                               PERSON COMPLETING SUMMARY

PERSON COMPLETING SUMMARY - Total                                       0             0        0            0             0

PERSON COMPLETING SUMMARY - Overall %                              #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

        HOSPITAL ADMISSION AUDIT - TOTAL                                0             0        0            0             0

TOTAL - Average % score of all records                             #DIV/0!       #DIV/0!    #DIV/0!      #DIV/0!       #DIV/0!

TOTAL - % score of all entries                                      #N/A          #N/A       #N/A         #N/A          #N/A
                                                                                                                   February 2011
           Hospital Discharge Audit Tool - Comments
Record 1




                                                      72
           Hospital Discharge Audit Tool - Comments
Record 2




                                                      73
           Hospital Discharge Audit Tool - Comments
Record 3




                                                      74
           Hospital Discharge Audit Tool - Comments
Record 4




                                                      75
           Hospital Discharge Audit Tool - Comments
Record 5




                                                      76
           Hospital Discharge Audit Tool - Comments
Record 6




                                                      77
           Hospital Discharge Audit Tool - Comments
Record 7




                                                      78
           Hospital Discharge Audit Tool - Comments
Record 8




                                                      79
           Hospital Discharge Audit Tool - Comments
Record 9




                                                      80
            Hospital Discharge Audit Tool - Comments
Record 10




                                                       81
                                           Hospital Discharge Record: Headings and Definitions

                                                                                    Definition/illustrative description of
                                                                                    the type of clinical information to be
       Headings / Sub-headings                                                          recorded under each heading
1    GP Details
     - GP name                          The name of the patient’s usual GP.
     - GP practice address              The name and address of the patient’s registered GP practice.
     - GP practice code                 Code which defines the practice of the patient's registered GP.

     Patient Details
2    Patient surname, forename

     Name known as
3    Date of birth
4    Gender
5    Patient NHS number
6    Patient address                    Patient’s usual address.
7    Patient telephone number(s)

     Admission Details
8    Method of admission                How the patient was admitted to hospital e.g. emergency, elective, transfer, maternity.
9    Source of admission                Where the patient was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal
                                        establishment.
10   Hospital site                      Physical site to which the patient was admitted.
11   Responsible trust                  The NHS Hospital Trust to which the patient was admitted (this may not be the same as the name of the hospital).

12   Date of admission
13   Time of admission                  Electronic environment only.

     Discharge Details
14   Date of discharge
15   Time of discharge                  Electronic environment only.
16   Discharge method                   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).
     Discharge destination
17      - type of destination           Can include private dwelling, penal establishment, care home etc (national code).
        - destination address           Not required if patient’s own home.
18      - living alone                  Yes or No.
19   Discharging consultant             The consultant responsible for the patient at time of discharge.
20   Discharging speciality/            The speciality/department responsible for the patient at the time of discharge.
     department
     Clinical Information
21   Diagnosis at discharge             Primary diagnosis, secondary diagnoses and relevant previous diagnoses, including complications and co-morbidities (e.g. for
                                        coding purposes).
22   Operations and procedures          New and relevant previous operations and procedures, including complications and adverse events.
23   Reason for admission and           The health problems and issues experienced by the patient resulting in their referral by a healthcare professional for hospital
     Presenting complaints              admission, e.g. chest pain, blackout, fall, a specific procedure, investigation or treatment.

24   Relevant Legal Information
     - Mental capacity                  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.
      - Advance decisions to refuse     Written documents, completed and signed when a person is legally competent, that explain a person’s medical wishes in
     treatment and Resuscitation        advance, allowing someone else to make treatment decisions on his or her behalf later in the disease process.
     status                             Includes Do not Resuscitate orders.

25   Allergies                          Allergies, drug allergies and adverse reactions.
26   Risks and warnings                 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.
27   Clinical narrative                 Very brief narrative description of the in-patient episode. Should include complications and nutritional status.

28   Relevant investigations and        The relevant investigations performed and their respective results, where present e.g. endoscopy, CT Scan etc. It is important
     Results                            to highlight investigations and test results which relate to a GP action.
29   Relevant treatments and changes    The relevant treatments which the patient received during the in patient stay. Can include medications given whilst an
     made to treatments                 inpatient.
30   Measures of physical ability and   e.g. Activity of Daily Living and cognitive function scale scores if not independent, weight/nutritional status at discharge.
     cognitive function
                                             Hospital Discharge Record: Headings and Definitions

                                                                                      Definition/illustrative description of
                                                                                      the type of clinical information to be
         Headings / Sub-headings                                                          recorded under each heading
31     Medication changes                 If admission medication stopped need to state reason. If medication started and stopped because of adverse reaction need to
                                          state reason.
32     Discharge medications              Can include:
                                          · Medication dispensed on discharge
                                          · Medication prescribed and not dispensed (eg patient’s own)
                                          · Medications to be commenced after discharge
                                          · NOMAD/ pill dispenser being used.
33     Medication recommendations         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.
       Advice, Recommendations
       and Future Plan

34 -   - Hospital                         Actions required/that will be carried out by the hospital department. To include:
36                                        ·    Action (e.g. Outpatient, pending investigations and results, outstanding issues)
                                          ·    Person responsible
                                          ·    Appropriate date and time
37 -   - GP                               Actions required by the GP. To include:
40                                        ·    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

41 -    - Community and specialist        Actions requested/ planned/ agreed with community services (community matron, palliative care, specialist nurse
43     services                           practitioner, rehab team, social services). To include:
                                          ·     Action
                                          ·     Person responsible
                                          ·     Appropriate date and time
44     Information Given to Patient       This can include:
       and/or Authorised                  ·     Relatives and carers
       Representative                     ·     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.

45     Patient’s Concerns, Expectations   The patient’s expressed wishes, expectations and concerns.
       and Wishes
46     Results Awaited                    Y/N (If Yes please specify). E4.g. pathology, investigations, imaging.

       Person Completing Summary
47     Doctor’s / Health Care
       professional's name
48     Grade / Designation
       - Specialty
49     Signature                          Only needed on paper discharge record.
50     Date of completion of discharge
       record
51     Distribution list

                                                                                                                                                          February 2011

								
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