Eight elements carry the admission to the clinician who takes over, each drawn from a named part of the admission record, and a named clinician corrects and signs the document before it leaves the hospital.
The eight elements
- 1. Principal diagnosis, and any change made during the admission (admission note, progress notes).
- 2. Procedures and significant events, including complications (operation reports, procedure notes, anaesthetic record).
- 3. Course of the admission: what was found, what was done, how the patient responded (progress notes, ward round entries).
- 4. Condition at discharge, covering mobility, wound state and cognition where any changed (discharge ward round entry, allied health notes).
- 5. Reconciled medication list, accounting for every start, cease, dose change and withheld medicine (pre-admission list, medication chart, pharmacist's reconciliation entry).
- 6. Results still pending, each with the clinician responsible for acting on it (pathology and imaging request lists).
- 7. Follow-up booked and follow-up the general practice is asked to arrange, each with a timeframe, and the interval and target for any test to repeat or dose to titrate (outpatient bookings, discharge plan).
- 8. What the patient and family were told about the admission, the medicines and the plan (the discharge conversation as recorded).
Medication reconciliation
A reconciled list sets what the patient took on admission against what they leave on: a ceased medicine with the reason, a new medicine with its intended duration and any monitoring, a dose change marked as a change, and a withheld medicine with a restart date and the clinician who owns the restart.
aurii does not draw the list from a live prescription record or a dispensing feed, and holds no connection to a practice-management system or hospital EMR.
Structure and length
A consistent section order across a service tells the receiving clinician where the medication changes sit. A summary names the results that altered treatment, with their dates, and leaves the rest in the record for the practice to request.
The review before signing
A named clinician reads, corrects and signs the document before it leaves the hospital.
- The diagnosis matches the diagnosis the team settled on at discharge.
- Every difference between the admission and discharge medication lists is stated, with a reason.
- Each pending result names the clinician responsible for acting on it.
- Each follow-up action carries an owner and a timeframe.
- Patient identifiers, dates and the discharge destination are correct.
Clinical handover
Standard 6 of the National Safety and Quality Health Service Standards, Communicating for Safety, covers communication at transitions of care, including clinical handover. The discharge summary carries that handover from the admitting service to the general practice.
The treating clinician remains responsible for the clinical content. Clinical safety.
Discharge summaries in aurii
aurii drafts a discharge summary from the admission documentation supplied to it. The clinician edits the draft, checks the medication list line by line against the chart, and signs.
Signed letters go out over Medical Objects. Integrations.
The principal diagnosis, procedures and complications, the course of the admission, the condition at discharge, a reconciled medication list, results still pending with a named owner, follow-up with timeframes, and what the patient and family were told. Each of those has a source in the admission record.
From the medication chart, the pre-admission history and the pharmacist's reconciliation entry as recorded during the admission. aurii does not read a live prescription record or a dispensing feed, and the clinician checks each line against the chart before signing.
No. A letter that has not been signed cannot be dispatched, and the draft becomes part of the record only once a clinician has reviewed it, corrected it and signed it.
This article is general information about discharge summaries and clinical handover. It does not constitute clinical or legal advice.