eDischarge summaries

Summary

Find out about eDischarge summaries, along with advice on how to implement them.

NHS England requires hospitals to send inpatient and day case discharge summaries to GP practices electronically. As of 1 October 2015, discharge summaries were no longer allowed to be sent by post or fax.


As of 1 October 2015, discharge summaries were no longer allowed to be sent by post or fax. As part of enabling information sharing across care settings, and in reducing the burden for general practice, the 2016/17 NHS England Standard Contract required providers to implement the Academy of Medical Royal Colleges (AoMRC) headings by 1st December 2016 when sharing inpatient and day case eDischarge summaries. This requirement is detailed in the NHS England Standard Contract Technical Guidance, section 39.22 

Transfer of Care Initiative resource library
A resource library of downloadable implementation guidance and supporting materials

Implementing Emergency Care discharge summaries in England
As part of the NHS England Standard Contract, providers must have aligned their Emergency Care discharges with the nationally published specification.

Implementing Outpatient clinic letters in England
As part of the NHS England Standard Contract, providers must have aligned their Outpatient clinic letters with the nationally published specification.

The Professional Record Standards Body (PRSB) has published the PRSB Standards for the Structure and Content of Health and Care Records which replaces the Academy of Medical Royal Colleges publication ‘Standards for the Clinical Structure and Content of Patient Records’ published in 2013. 

The PRSB standards have been updated to reflect current professional practice and incorporate new or changed structured content resulting from the development of detailed transfer of care standards. They have been developed with input from thousands of professionals from all health and social care specialties, carers and people who access services. They agreed what information is essential to share in order to provide timely, high-quality care efficiently that is well-coordinated and meets an individual’s needs.

This is the first major release since 2013 and PRSB has produced guidance, FAQs and other materials to help organisations and system suppliers replace previous versions of the standards in their information systems. 

 

The PRSB eDischarge summary standard detail the headings that must be implemented by 1 October 2018.

Learn how two hospitals have successfully implemented headings in their eDischarge summaries to ensure consistent recording of information, to improve the quality of information shared with GPs and to enhance audit data.

Read the Papworth Case Study.

Read the Oxleas case study.

How to implement Headings

1.    Download the quick guide for an outline approach for managers leading on the implementation of headings in eDischarge summaries

2.    Download the implementation toolkit for detailed guidance on the headings. A PDF version is also available.

Providers are reminded that as detailed in the NHS England Standard Contract from the 1 October 2018, they must have aligned their eDischarge summaries with the nationally published specification.

Transfer of Care documents must be sent within England (in and out of catchment area) by any direct electronic transmission including proprietary solutions, except email, using a structured and coded message specification capable of carrying SNOMED CT encoded diagnosis, procedures, allergies and dm+d encoded medication information.

NHS Digital has adopted Fast Healthcare Interoperability Resources (FHIR) based structured document standards for Transfer of Care. Download the Transfer of Care FHIR specifications

The Transfer of Care FHIR messages will use the ITK3 (Interoperability Toolkit) specification available here:  https://developer.nhs.uk/interoperability-tool-kit-itk-specification-versions/

For further advice and support, contact information.standards@nhs.net

 

Videos - clinical and IT leaders discuss the use of headings

Further information