Hospital discharge summary timing and delivery to the GP

The hospital's medical records policy sets the completion window for the discharge summary, and the Communicating for Safety Standard in the National Safety and Quality Health Service Standards covers the clinical handover that discharge to a general practice is. In aurii the discharge note and the GP discharge summary are drafted together from the admission record on the discharge round, the specialist signs them, and the summary leaves for the nominated GP over Medical Objects on sign-off with the acknowledgement written back against it.

Two documents come off the discharge round. The discharge note is the day-of-discharge entry in the inpatient record and stays with the hospital. The GP discharge summary is the letter to the practice, with the summary attached, and it is what Medical Objects carries.

In aurii the discharge round is where both are written. A spoken review at the bedside drafts the discharge note and the GP discharge summary against the patient record, and both wait for sign-off with the round's ward note. Sign-off is the point at which the summary leaves, so the specialist who signs on the round sends the summary on the day of discharge.

The Standard treats discharge as clinical handover. Its handover actions read directly onto the discharge summary.

The Medical Board of Australia's Good Medical Practice code carries the same obligation for the individual doctor. At 6.3.4, under Delegation, referral and handover, it asks the doctor to always communicate sufficient information about the patient and the treatment they need to enable the continuing care of the patient. For a private admission the signed summary and its delivery status are the record of that handover.

The summary is drafted from the admission's notes, letters and results held on the patient record, and each element of the summary is drawn from a named part of that record.

The GP discharge summary letter draws the admission, the hospital course, the discharge details and the follow-up ask from the same record. Its follow-up block asks for review in the GP's rooms and points the practice to the attached summary for the agreed actions. The specialist edits the draft and signs, and the clinical content is the specialist's.

The GP on the patient record is the recipient. The practice is named on admission, so the recipient is set before the discharge round. aurii checks that the practice is routable on the Medical Objects network before dispatch and refuses a dispatch to a practice that is not, so the clinician chooses another route for that practice before signing.

Before signing, check the summary against the record: the diagnosis, every medication change with its reason, the clinician who owns each pending result, and the patient identifiers, dates and discharge destination.

Start from the GP discharge summary template for the letter that goes to the practice with the summary attached.

• The recipient is the patient's usual GP at the practice named on admission, and the practice is routable on Medical Objects.
• After sign-off, the status against the summary reads acknowledged. A failure is signed off again for resend, and a summary that has not returned an acknowledgement is followed up with the practice.