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.

  • 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.

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.

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 (seeMeteor). 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 displays 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. For more information, see Writing letters and referrals.
      4. Click Save and Upload to My Health Record.
      5. 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 or print the document in the usual way. Send the Discharge Summary securely using Secure Messaging: click Send Secure. For more information, see Writing letters and referrals.

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

Tip:
If you are sending the discharge summary using PDS and the recipient cannot receive the document you attempted to send, you will see one of the following errors:
Table 1. Errors displayed if recipient cannot receive the discharge summary
Action Error if recipient cannot receive the discharge summary
Create a discharge summary and send as a letter The selected recipient cannot receive this document type
Create a discharge summary and send as CDA Communicare cannot send CDA discharge summaries via secure messaging