Guideline 65: The immediate discharge document

The immediate discharge document
Section 3: The Immediate Discharge Document

Item	Field	Notes
	tems shown in bold are essential Items not in bold are desirable
1 Hospital	Text field	*
2 Patient ID	national id number local id number title first forename preferred forename surname address 1 address 2 address 3 address 4 postcode date of birth occupation	CHI is recommended *
3 Preferred GP ID	forename surname address address 1 address 2 address 3 address 4 postcode	The minimum dataset requires that the discharge summary is sent to the preferred GP. In the absence of a preferred GP it should be sent to the GP with whom the patient is registered. Multiple copies of this document may be required, eg patients not returning to their own home immediately.
4 Consultant ID	forename surname specialty	An immediate discharge document should be produced after each significant episode, eg moving from a surgical to a general ward.
5 Ward/Department	text	The ward or department issuing the IDD should be specified.
6 Date of admission/transfer	date	To the unit issuing IDD. This may be a transfer from another unit.
7a Date of discharge/ transfer	date	From the unit issuing the IDD. This will include transfer to another unit. 7a & 7b are mutually exclusive.
7b Date of death	date	7a & 7b are mutually exclusive.
8 Reason for admission/transfer	text code	Description of complaint or reason for admission This may be coded.
9 Mode of admission	choice	Elective, emergency or transfer.
10 Source of admission	text	Source of referral for this admission.
11 Diagnosis/problems (multiple)	text code(s) provisional/confirmed	Text description should be given for each significant condition The diagnosis should be described When possible standard code(s) should be provided It should be made clear whether the diagnosis is provisional or confirmed.
12 Significant operations/ procedures (multiple)	text code(s) date of procedure	Operations/procedures (eg chemotherapy) should be described When possible standard code(s) should be provided Named consultant not required if IDD issued after each significant episode or event as already given in field 4.
13 Relevant investigations	text code(s)	Relevant investigations performed should be described Standard codes optional.
14 Complications (multiple)	text code(s)	Complications should be described (medical and/or surgical) When possible standard code(s) should be provided.
15 Medication on discharge (multiple fields as required)	name of drug (generic where possible) formulation current dose dose changed drug stopped new prescription route of administration frequency length of treatment supply given to patient start and stop dates (where relevant) reasons for starting and stopping (where relevant) compliance aids Y/N /text	The minimum dataset is not a discharge prescription, however a full prescription history is advised unless the IDD follows an episode that does not result in a change to long term medication Start and stop dates for short or defined courses of treatment should be detailed Details of whether compliance aids are required or already given to the patient should be provided. If already provided, detail whether being used or not.
16 Adverse reactions	Text	Include all known allergies
17 Discharge plans	destination - text review at hospital Y/N mobility / disability (see below) care arrangements made Y/N care arrangements - text information to patient? Y/N / text information to carer or relative? Y/N / text early GP review recommended? Y/N /text	Further information eg destination to care home Comment on whether hospital review required Review date and by whom Care arrangements made - this will vary greatly according to patient type eg district nurse/social worker /carer for elderly patients, none for others. Other agencies involved and eligibility for higher or lower free care should be noted Information to patient, include whether written or verbal or both. If yes, explanatory text required Information to carer or relative, include whether written or verbal or both If early GP review recommended, explanatory text required.
18 Information to patient and/or carer/relative	Y/N sickness certification issued Y/N/NA	If sickness certification issued state duration.²⁹
19 Comment	free text to amplify minimum data	Optional - not required for straightforward admissions
20 Results awaited	Y/N (If Y specify)	eg pathology, investigations, imaging
21 Letter to follow	Y/N
22 Contact	Telephone number	The minimum information required is an appropriate contact telephone number - to be decided locally.
23 Signature & name & rank/position	Signature Legible text of name Job Title	To be completed by the responsible person at the time of discharge eg resident, sister, senior nurse or senior medical staff. They are signing on behalf of the person named in field 4 who is responsible for the document.

*In an electronic system these data should be downloaded from a Patient Administration System (PAS) file

Disability Scale adapted from Rankin Scale³⁰	Mobility Scale adapted from Royal College of Physicians National Sentinel Audit³¹
0 = well, no symptoms	0 = bedridden or wheelchair bound
1 = minor symptoms not affecting lifestyle	1 = sits without support
2 = minor handicap but independent in self care	2 = walks with help of another person
3 = moderate handicap but needing a little help with activities of daily living (ADL)	3 = walks with aid
4 = needing a lot of help with ADL	4 = walks 5 metres without aids
5 = needing constant attention day and night	5 = able to walk 200 metres outside