A discharge summary is defined as "A collection of information about events during care by a provider or organisation." [AS4700.6(Int)2007]. It comprises a document produced during a patient's stay in hospital.
Discharge summaries in the Australian context
An Australian Institute of Health and Welfare report totals 756 public and 561 private hospitals in Australia who will potentially be a source of discharge summaries, and some 22,589 (20,029 FTE) primary care practitioners who will likely be a recipient of a discharge summary.
There are also about 8.1 million hospital separations per year in Australia, of which around 57 per cent are same-day admissions [AIHW-AHS2010]. Note: Many same-day admissions (e.g., patients who are admitted for dialysis, same-day chemotherapy and other procedures involving repetitive same-day admissions) would not normally require a discharge summary.
Unlike the pathology or medication sub-sectors, there are currently no specific national or state legislative or regulatory requirements for discharge summaries. However, a number of position statements from peak, state and national bodies are available (e.g., the Australian Medical Association).
Jurisdictions maintain their own policies and individual hospitals and area health services use more detailed policies.
Context in digital health
There are a number of key business flows that occur within digital health in Australia, as outlined in Figure 1 below.
Figure 1: Discharge summary high-level overview
These flows are described below:
- Upon discharge of a patient, the clinician creates a discharge summary in their local hospital system.
- The authoring system sends the discharge summary to the intended recipient(s). These could be communicated via electronic secure messaging channels or fax.
- The authoring system sends the discharge summary to the consumer’s My Health Record.
- Anyone with relevant access to the consumer’s My Health Record can access the discharge summary.
Specifications, guidance and associated collateral applicable to all types of clinical documents.