Guideline 65: The immediate discharge document

The immediate discharge document
Section 1: Introduction

1.1 The need for a review of the immediate discharge document

The original SIGN Immediate Discharge Document (IDD) was published in 1996.¹ Since then, there have been major initiatives intended to improve documentation within, and communication between, primary and secondary care. A number of areas in Scotland have implemented the original IDD dataset, in particular those areas where electronic communication is being developed or considered. Whilst these technological initiatives have been a major stimulus to review the IDD dataset, conventional paper documentation is likely to remain a major feature of clinical practice for the foreseeable future. Few would deny the manifest deficiencies of existing documents and the potential benefit of a structured approach.

In 1998, the Accounts Commission for Scotland² suggested that: Trusts should review their discharge documentation to ensure that it captures and disseminates the information required and aids high quality multidisciplinary discharge management.

By refining the SIGN dataset and encouraging a more disciplined approach to discharge documentation it is hoped that standards in this critical area of practice will be improved.

1.2Rremit of the immediate discharge document

The IDD is an important instrument for communication between secondary and primary care. There is continuing evidence that the quality of immediate discharge documents used in NHSScotland fall far short of the ideal. These deficiencies occur in the content, structure and production of the document. The original IDD proposed a minimum dataset to address these issues.¹ The specification of a revised minimum dataset has implications for a number of contemporary activities related to data capture and document production.³

There are important implications for all clinical parties and for patients, their representatives and carers in the expeditious and accurate production of discharge documents. The dataset for the IDD should permit the production of a single discharge document for the maximum number of patients and serve as the template for the final document for the remainder. This document refers to the immediate discharge document that should be available at the time of patient discharge. Subsequent information may be necessary and this should be delivered as quickly as possible.

The IDD is of relevance to all hospital medical and nursing staff, allied health professionals, general practitioners (GPs), community nurses and pharmacists.

The IDD and the dataset are not exclusive and additional documentation is often required to supplement this minimum. For many patients a detailed care plan is necessary to inform carers and relevant support organisations and this should involve all relevant members of the multidisciplinary team.

1.3 Confidentiality

The IDD contains personal data and is subject to the Data Protection Act (1998) that covers manual records.⁴ The principles of data protection as stated in the Act and the recommendations of the Caldicott Committee, in particular the recommendation that all data flows should be tested against basic principles of good practice, have been considered. NHS staff should also be aware of the Scottish Executive Confidentiality and Security Advisory Group for Scotland (CSAGS) report which outlines both the principles of confidentiality (section 12) and the importance of consent in data processing (section 7).⁵ Further details are available on the SIGN website www.sign.ac.uk

1.4 Statement of intent

The IDD is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of practice should be considered guidelines to assist in optimising local practice.

1.5 Updating

This guideline was issued in 2003. Any updates to the manual will be noted on the SIGN website: www.sign.ac.uk