Concept of Operations: Relating to the introduction of a Personally Controlled Electronic Health Record System
4.3.3 Discharge SummariesThe PCEHR System will support collection of Discharge Summaries. When a healthcare provider creates a Discharge Summary, it will be sent directly to the intended recipient, as per current practices, and a copy of the Discharge Summary may also be sent to the PCEHR System.
A Discharge Summary may be provided as a level 1, 2 or 3 clinical document.
Structured Discharge Summaries must conform to the forthcoming Standards Australia specifications based on the NEHTA specifications [NEHTA2010e].
In addition to the common fields, a Discharge Summary may contain:
- Nominated primary healthcare providers14 (optional)
- Document recipients (required)
- Encounter details (required)
- Problems/diagnoses (including principal, complications and co-morbidities) (required)
- Clinical synopsis (required)
- Diagnostic investigations (optional)
- Clinical interventions (optional)
- Current medications on discharge (required)
- Ceased medications (required)
- Allergies and adverse reactions (required)
- Alerts (optional)
- Arranged services (optional)
- Recommendations (required)
- Information provided to patient and/or relevant parties (optional)
- Attachments (optional)
|Scope Notes: Note that NEHTA Discharge Summary specifications are currently limited to the context of discharging an individual from an acute setting hospital and may not cover the specific requirements for some specific settings. Other forms of Discharge Summary will be supported via level 1 clinical documents in the first release.|
|eHealth Site Notes: All wave 1 sites and a number of wave 2 sites will be informing the creation and management of discharge summaries.|
14 Note that the NEHTA discharge summary specification predates the PCEHR System Concept of Operations. The nominated primary healthcare provider is a term identified in that document as the intended recipient of the discharge summary. This term should not be confused with the Shared Health Summary Nominated Provider.
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