Immediate Discharge Letter

Introduction

There have been a number of clinical incidents over the past few months in relation to discharge tasks and immediate discharge letters (IDLs).
We need to ensure we standardise the discharge process, throughout the hospital, to ensure patient safety. This is especially important with junior medical staff are moving around frequently.

How to Write One

1. Go to HEPMA and click on ‘Discharge Rx’
2. Click on ‘Add drug from inpatient’.  Click days to supply (default is 7 days).
3. Click on ‘Discharge Letter’
4. Select your name from the dropdown list
5. Click ‘Save’ and close box
6. Click on ‘Complete Discharge’.
7. Click on ‘Send Order to Pharmacy’
8. You need to close the letter and reopen it before the medications appear on your screen.
9. 9Then fill in the clinical boxes eg patient history and new meds started or meds stopped.
10. Click’ Print Pharmacy copy’ unless no Pharmacy intervention is needed (less common)
11. Syringe driver prescriptions go on paper chart which goes with patient and don’t need to go on Hepma.
12. For controlled drugs, you need to add an order note.  Click on ‘Note to appear in D/C letter’.  Add note using numbers and words.  Click ‘save’.

Ten Steps to a Perfect IDL

1. It is the discharging team’s responsibility to ensure tests are requested; referrals are made and follow up appointments booked.
2. The discharging doctor (the doctor who completes the IDL) should ensure that all these things are done at the time of discharge and document in the discharge letter the tests that have been requested. Similarly any referrals made should be documented.
3. It is not the GP’s job to order or chase the results of tests arranged during the admission or at discharge. GPs may be asked to do follow up tests that can be easily arranged in the primary care setting, for example blood tests, but should not be asked to arrange follow up scans or chase results of scans. If you are unsure what is appropriate ask senior staff.
4. New referrals needed at the time of discharge, should be made by the discharging doctor. See referrals to specialist teams on discharge below.
5. It is important to ensure the field: “Which clinical problem needs addressed by speciality team at review?” is clear and if you are unsure this should be checked with senior staff. Brief relevant clinical information should be included with the referral. If this information is already in the IDL then this could say ‘please see IDL’ and attach a copy of the IDL to the referral form. It is NOT appropriate to ONLY send a copy of the IDL as a means of referral. Referral forms should go to the discharging team secretaries to be put onto RMS. Urgent referrals need to be taken directly to the secretaries.
6. It is not appropriate to assume a team will follow up a patient because they have a problem related to that speciality (ie abnormal CXR or USS which needs a follow up imaging). A lot of things can be followed up by the discharging team. Discuss with a senior whether referral is needed and then make an appropriate referral if required.
7. Follow up appointments with a team that is not the discharging team, but has either seen or discussed the patient, and wishes to see them as an outpatient should be arranged by that team. They may ask to be notified when the patient is discharged home, and this should be done by a phone call to them or their secretary. It is not appropriate to rely on a copy letter having been sent as this may get missed.
8. Outpatient follow up with the discharging team should be arranged as follows depending on the speciality. Staff should not rely on follow up appointments being picked up from the IDL, although secretaries should still check the IDL and raise with teams instances where the appointment was not made.
   • Medicine – phone call to the secretary
   • General Surgery, Orthopaedics and Gynaecology – via the ward clerk (there should be systems in place on these wards for the ward clerk to pick up appointments if they is not immediately available ie: doesn’t work in the afternoon). If a patient is boarded to another ward and a ward clerk is not available then an appointment should be arranged by phone call to the secretary.
   • A follow up appointment is not always needed, please check with senior staff before booking one.
9. If an IDL is pre populated it is the responsibility of the discharging doctor to ensure it is complete and all discharge jobs are requested, prior to printing it off for pharmacy.
10. MEDICAL/SURGICAL STAFF should help this process by documenting clearly in the notes if they make a referral or requested a test. eg CT chest requested, referral to renal sent.

Referrals to Specialist Teams on Discharge

Links

• Referral Form