Discharge Summary

Product

Context

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.

Discharge Summary Diagram

Figure 1: Discharge summary high-level overview

These flows are described below:

  1. Upon discharge of a patient, the clinician creates a discharge summary in their local hospital system.
  2. The authoring system sends the discharge summary to the intended recipient(s). These could be communicated via electronic secure messaging channels or fax.
  3. The authoring system sends the discharge summary to the consumer’s My Health Record.
  4. Anyone with relevant access to the consumer’s My Health Record can access the discharge summary.
Specifications
Current Specifications: 
Identifier: 
EP-2656:2018

Discharge Summary documents support the transfer of a patient from a hospital back to the care of their nominated primary healthcare provider.

Supporting Specifications: 
Identifier: 
EP-2655:2018

Specifications, guidance and associated collateral applicable to all types of clinical documents.

Identifier: 
EP-1826:2014

The supporting documents on this page provide background and guidance for healthcare provider organisations, and conformance, compliance and accreditation requirements for vendors.

Identifier: 
EP-1011:2012

The National Authentication Service for Health (NASH) makes it possible for healthcare providers and supporting organisations to securely access and exchange health information.
NASH provides Public Key Infrastructure (PKI) Certificates that help you or your organisation to:

By operation of the Public Governance, Performance and Accountability (Establishing the Australian Digital Health Agency) Rule 2016, on 1 July 2016, all the assets and liabilities of NEHTA will vest in the Australian Digital Health Agency. In this website, on and from 1 July 2016, all references to "National E-Health Transition Authority" or "NEHTA" will be deemed to be references to the Australian Digital Health Agency. PCEHR means the My Health Record, formerly the "Personally Controlled Electronic Health Record", within the meaning of the My Health Records Act 2012 (Cth), formerly called the Personally Controlled Electronic Health Records Act 2012 (Cth).

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