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Discharge summaries

The discharge summary is a crucial document for safer and better quality continuity of care.ﾠ A timely and high quality discharge summary is essential for the family doctor or paediatrician to provide appropriate ongoing care after a child leaves hospital.ﾠ It alsoﾠgives parents a valuable record of their child's hospital stay.

How to write a discharge summary in CLARA

  • Want a quick session on how to use CLARA to do summaries?
    Contact Quality and Improvement Registrar cqs.registrar@rch.org.au / x4918

How to write a GOOD discharge summary

Howﾠto get your unit list of outstanding summaries

  • At the top of this page you'll find a link to the latest update of outstanding summaries.ﾠIt's an excel document, on the Intranet only (means you can't access it from outside the hospital) and is password protected. Call Kids Connect for the password.ﾠIt contains patient names so please dispose of your list carefully.
  • You can also print a list from CLARA. ﾠFor some units the CLARA list includes patients who actually don't need a summary (ie. certain day/ongoing treatment patients who don't need a daily summary).ﾠTry it for your unit to check if it is relevant.

Log on to CLARA:

  • Click on list
  • Click on discharge summaries
  • Click on the DISCHARGED button on left hand side column (important!)
  • Click on Start date (not longer than 3 months)
  • Click on End date (today)
  • Click on the unit you want the list for
  • Click on FIND

How to get records for summaries outstanding

  • CallﾠHealth Information Services x6114 (Sue Stubbings or Graham Paul)
  • Provideﾠyour list of patient names /ﾠUR numbers and let them know where you want the records to be sent.
  • You can also fax them your list - fax 6589 (remember to include your contact pager number).
  • You can also go down to HIS to do your summaries down there.  That might be quicker, especially during 'coding time'.

What's the hospital policy for timeliness of discharge summaries?

The RCH Policy is that discharge summaries must be complete within 48 hours of the patient leaving hospital and must be completed electronically on CLARA.ﾠ See:

 HIS staff ready to help MEDICAL RECORDSﾠ
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Who actually writes the discharge summary in each unit?

The discharge summary should be written by 'the most appropriate person' who is involved in a child's care .ﾠThis may be a junior or senior doctor, care manager or other senior specified nursing staff (usually in conjunction with medical staff).ﾠNursing staff write discharge summaries in the Day Medical Unit and Care Managers can write or contribute to summaries in all units.

If you write a summary for a patient you do not know, please include a statement in the summary such as "I had no direct involvement in this child's care" and include a contact number should the receiving doctor wish to discuss care with one of the treating staff (could be doctor, care manager or NUM).

What happens to completed summaries?

Discharge summaries get sent to the doctor recorded on the patient record.ﾠ Generally this is the usual family doctor.ﾠA copy should also be sent to the referring doctor - which may be a GP or paediatrician.ﾠAsk on the ward who sends the summariesﾠ- at the moment it varies from ward to ward.ﾠSometimes it is the ward clerk who posts or faxes the summary, sometimes the summary stays with the record and HIS sends them and some doctors choose to fax or post them personally.

Ideally, discharge summaries are completed on discharge and given to the family before they leave.ﾠThey should have the chance to read the summary and make sure they understand what happened in hospital, follow-up care and ask any questions before they leave.

If you write a summary for a patient you do not know and the summary contains information that may not have been discussed with the family (for example a new diagnosis) do not send a copy to the family.ﾠPlease ensure you write on the GP copy "No copy to parents".ﾠBear in mind parents may always see a copy of the summary at some point.

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What's been done to help improve outstanding summaries?

  • Printers do not have the delays any more - used to be up to 3 hours.  If your printer is experiencing delays, call ICT x6277, ask them to 'reboot the printer server'
  • Child Cancer Centre, Haematology and Nephrology all determined exclusion criteria for day-stay patients who do not need a summary.
  • The Relief team can help your unit call Rosemary in theﾠJMSD office on x5144.
  • We are tracking the number of legitimate outstanding summaries where there is a trend you have a good case to present to your HoD for more staffing or support!
  • Day Surgery Unit: work-in-progress
  • Trialing 'discharge day' stickers on the 5th floor and prioritising most recent dishcarged patients first.
  • Results?
    • In February 2007 the RCH had 465 outstanding, with a 50% reduction at 238 outstanding in February 2008!ﾠ
    • And in 2007 HIS staff say medical staff were MUCH BETTER than the year before in getting summaries done before the records hit HIS - so we have a big improvement over the past 2 yearsﾠ- thanks to you and your predecessors.

Contacts

To get records for outstanding summaries contact Health Information Services:

  • Sue Stubbings or Graeme Paul x6114
  • HIS Manager Cameron Barnes x6106
  • Fax your list to HIS fax 6589

To volunteer your services to help with outstanding summaries

(yeah, right, we know!!! - but you'll instantly win a Lonely Planet guidebook...)

  • JMSDﾠoffice - Rosemary x5144
  • HIS Manager Cameron Barnes x6106
  • HIS Sue Stubbings or Graham Paul x6114

 

Last Updated 28-Apr-2009. Authorised by: Annie Moulden. Enquiries: Susan Jury.
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