It’s time to talk:
“Medicines information in the Discharge
Summary”
Presenter
Insert your
hospital logo
here
Explaining changes on the discharge medicines list
Aims
•
•
•
To provide an understanding of the typical
gaps seen in the provision of discharge
medicines information to GPs.
To describe practical and efficient
methodologies to address gaps and
communicate comprehensive medicines
information on the discharge summary
To gain feedback on current challenges when
attempting to complete comprehensive
discharge summary medicines information
Explaining changes on the discharge medicines list
-Case report 1
• Patient presents to hospital after generalised tonic-clonic seizurefirst one.
• Patient commenced on Phenytoin
• Required to remain in hospital for an extended period due to subtherapeutic Phenytoin level
• Discharge medicines list stated the patient was on 450mg Phenytoin
at night. Patient’s carer reports to GP that the dose is 300mg at
night. (unpublished)
What safety issues does this raise for the GP?
How could these have been avoided?
Explaining changes on the discharge medicines list
-Case report 2
• Patient presents to hospital for admission due to
ischaemic foot:occluded left popliteal artery
• PMHx includes: PVD, HTN,
Hypercholesterolaemia, IHD, GORD, THR(Right)
• Patient remained in hospital 3wks…
• Discharge medication list: “Aspirin” (unpublished)
Explaining changes on the discharge medicines list
The discharge summary: why is it
needed and what is required?
Needs:
• Frequently, the discharge summary is the only
communication provided to the General
Practitioner (GP) about their patients’ and the
events that occurred whilst their patients’ were in
hospital.
Requirements:
• Complete
•Legible
• Accurate
•Concise
Explaining changes on the discharge medicines list
What is the evidence- gaps in practice?
Evidence in Australia and internationally
shows there are deficiencies in the quality
of the information documented in the
discharge summary for GPs, Patients and
Carers
Explaining changes on the discharge medicines list
Completing high quality discharge
summaries
NEHTA Continuity of Care program March 2010*
Barriers include:
• lack of support
• time
• uncertainty over what information a GP
desires
*Continuity of Care Program- National E-Health Transition Authority, March 2010: Issues and barriers faced by Junior
Hospital Doctors for the Implementation of the Discharge Summary
Explaining changes on the discharge medicines list
What do we want to achieve?
Improvement happens slowly over time…we need a
starting point:
Discharge medication list in the
discharge summary
Specifically, improve documentation to include:
• All medications a patient is to continue taking after discharge
• All explanations for changes to medication therapy
• Ceased medications
Explaining changes on the discharge medicines list
Defining “changes” to and
“explanations” for medication therapy?
Refers to changes to the patient’s pre-admission
regimen which are intended to continue after discharge2
– New medication
– Change in the dose, form, route or frequency of a
medicine taken prior to admission
– Cessation of a medicine taken prior to admission
Explanations for changes: Should include sufficient detail
to inform future management decisions in the discharge
summary or discharge letter.
Explaining changes on the discharge medicines list
Throughout the patient
journey…
Explaining changes on the discharge medicines list
Top Tips
1. Know where the Best Possible
Medication History (BPMH) is located
(In our hospital, the BPMH is located…)
Why?
•Consistency
•Collation (reconciliation)
Explaining changes on the discharge medicines list
Top Tips continued…
2. ALWAYS document as you go; the
changes made to medications and ceased
medications, WITH reasons
- if you don’t know why, please ASK!
Why?
• Safety and continuity of care
• Clarification
Explaining changes on the discharge medicines list
At patient discharge…
Explaining changes on the discharge medicines list
Top Tips
1. Include all medications the patient is to
take after hospital discharge on the
discharge summary
Why?
• To ensure continuity of care
• To save your time
Remember! Any change made on the prescription must have the
equivalent change made on the discharge summary
Explaining changes on the discharge medicines list
Top tips continued…
2. Document explanations for changes to
medicine therapy as described in patient
notes.
Why?
• Clarifies the intention of the medication
change
• Is the final medication record prior to
discharge
• Time saving
Ensure explanations are placed in the appropriate area
Explaining changes on the discharge medicines list
Top tips continued….
3. Legibility!
Why?
Communication….
-This document is only effective when the
information can be clearly understood.
-It will be used by GPs, patients and/or carers
-It may even be referred to again by you or
clinicians in your hospital at next
admission/appointment
Explaining changes on the discharge medicines list
The good, the great and the ugly…
What a GP needs versus what is provided
Explaining changes on the discharge medicines list
Good D/C Summary
• Please insert your discharge summary
here
Explaining changes on the discharge medicines list
Questions?
• Discussion
Explaining changes on the discharge medicines list
Where to from here?
NSW Therapeutic Advisory Group Discharge
Summary Improvement Program
Tools to assist:
• Lanyard cards
• Term Supervisor walk-through for use at
assessment time
Practice and reflection
Explaining changes on the discharge medicines list
Support
• Hospital coordinator contact: XXXX
• Clinical Champion: XXXX
• Other
Explaining changes on the discharge medicines list
Workshop discharge summary examples
Explaining changes on the discharge medicines list
Continuing improvements
•
3 common problems with the discharge
medicines list: unjustified and omitted
medicines, changes to dose, route, frequency.
•
What can you do in your every day practice to
assist continuity of patient care and patient
safety in order to write the best possible
discharge summary for your patient’s?
•
TOP-TIPS lanyard cards
Explaining changes on the discharge medicines list