Discharge Summaries

Communicare can create and send Discharge Summaries either in the CDA format (compliant with eHealth standards in Australia) or in a less constrained RTF format. RTF format Discharge Summaries cannot be sent to MeHR, whereas CDA format documents can be sent to either My Health Record or MeHR.

A discharge summary is a collection of information about events during care by a provider or organisation, which is released when the subject of care is discharged from the care of the provider organisation.

Prerequisites

  • The Discharge;hospital;summary Clinical Item must be enabled. See Clinical Item Types.
  • Encounter places must have a valid HPI-O configured.
  • The current Provider must have a valid HPI-I.
  • The patient must have a valid IHI.
  • If you plan upload to the My Health Record, My Health Record must be configured . See My Health Record.
  • If you plan to send via secure messaging, Secure Messaging must be configured. See Secure Messaging.

Creating and Sending Discharge Summaries

To create and send a discharge summary:
  1. Open the clinical record for the patient for whom you want to create a discharge summary and add a new clinical item of type Discharge;hospital;summary.
  2. Complete the discharge information. All fields must be completed if a CDA format document is required and HPI-O, HPI-I and IHI are also required. HPI-O, HPI-I and IHI health identifiers are not required for RTF format.
    • Clinical Synopsis - summary information or comments about the clinical management of the patient, and the prognosis of diagnoses and problems identified during the healthcare encounter. It may also include health related information pertinent to the patient, and a clinical interpretation of relevant investigations and observations performed on the patient (including pathology and diagnostic imaging).
    • Hospital Discharge Date - the date that the patient was discharged from hospital, on or after the admission date.
    • Hospital Admission Date - the date that the patient was admitted to hospital.
    • Separation Mode - status at separation of the patient and place to which the person is released, based on the Australian Institute of Health and Welfare's Mode of Separation (see http://meteor.aihw.gov.au/content/index.phtml/itemId/270094). Must be one of the following values:
      • Discharge/transfer to (an)other acute hospital
      • Discharge/transfer to a residential aged care service, unless this is the usual place of residence
      • Discharge/transfer to (an)other psychiatric hospital
      • Discharge/transfer to other health care accommodation (includes mothercraft hospitals)
      • Statistical discharge - type change
      • Left against medical advice/discharge at own risk
      • Statistical discharge from leave
      • Died
      • Other (includes discharge to usual residence, own accommodation/welfare institution (includes prisons, hostels and group homes providing primarily welfare services))
    • Primary Healthcare Provider - the health care provider nominated by the patient as being primarily responsible for their ongoing health care, taken from the address book. The provider must have an HPI-I and HPI-O.
    • Discharge Arranged Services - services that have been provided for or arranged for the patient.
    • Discharge Recommendation Recipient - a person or organisation at whom the discharge recommendation is directed, taken from the address book. If the recipient is a person, that person must have an HPI-I and an HPI-O. If the recipient is an organisation, that organisation must have an HPI-O.
    • Discharge Recommendation - recommendations to a recipient healthcare provider or subject of care that are relevant to the continuity of care and management of the subject of care after discharge. This may include information such as: information and education that has been provided to and discussed with the patient, their family , carer or other relevant parties, including awareness or lack of awareness of diagnosed conditions, and relevant health management; an indication of whether the patient or carer has understood the information or instructions provided; information or recommendations given by a health care provider during the health event to another health care provider responsible for the ongoing care of the patient.
  3. Once you have filled in all the discharge details, either:
    • For a CDA Discharge Summary, click Save & Create eDischarge Summary. The View Discharge Summary window is displayed, showing a tree view of the document on the right and a preview on the left. Communicare will have gathered the required information based on the data entered in the Discharge Summary clinical item, and any clinical information that has been entered against the patient within the date range of the hospital visit required for the summary document, as entered on the Discharge Summary clinical item.
      1. Use the tree to exclude any clinical information listed that is not relevant, or needs to be excluded from the document.
      2. In the Details panel at the bottom of the window, from the To field, select a document recipient.
      3. When ready, save, print, or upload to the My Health Record and send it in the same way as other documents.
      4. Click Save and Upload to My Health Record. If you have previously uploaded a discharge summary, set Supersede to replace the previous My Health Record document with a new document from Communicare.
    • To write a discharge letter in RTF format, click Save & Write Discharge Summary.
      1. In the Write a new Discharge Summary Letter window, write a letter.
      2. When the required edits are complete, save, print or send the document in the usual way.

Results

If you chose the eDischarge option, the document is queued and will upload to My Health Record at the next upload.

eDischarge CDA Document Summary Data Sections

Problems/Diagnoses This Visit - contains any condition class clinical items that were recorded between the admission and discharge dates.

Clinical Interventions Performed This Visit - contains any procedure class clinical items that were conducted between the admission and discharge dates.

Clinical Synopsis - populated from the free text field on the Discharge;hospital;summary clinical item.

Diagnostic Investigations - contains any investigation results for investigations that were conducted between the admission and discharge dates.

Current Medications On Discharge - contains medications recorded in Communicare that the patient will continue or commence on discharge.

Ceased Medications - contains any medications recorded in Communicare that were stopped, cancelled or ran their course between the admission and discharge dates.

Adverse Reactions - lists any adverse reactions that the patient has recorded in Communicare. See Clinical Record - Summary Tab.

Alerts - lists any alerts that the patient has recorded in Communicare. See Clinical Record - Summary Tab.

Arranged Services - populated from the Discharge;hospital;summary clinical item.

Record of Recommendations and Information Provided - populated from the Discharge;hospital;summary clinical item.

Participants - contains all providers that recorded a service for this patient in Communicare between the admission and discharge dates.

Primary Recipients - contains the details of the discharge summary recipient selected in the To field of the document view window.