South Australians discharged from hospital are to have a smoother transition to the care of their GP as the Central Adelaide Local Health Network (CALHN) overhauls its medical discharge summaries.
CALHN said the move followed a successful trial period which led to a reinvented template being embedded in the CALHN policy.
“These summaries are critical to ensure the continuity of patient care with their new healthcare provider once they have been discharged from hospital,” CALHN said.
“Prior to the project, there was no universal template or guidance to support junior Medical Officers in how they brief GPs regarding outgoing patients,” it said.
Hematology Registrar and Project Lead for CALHN, Andrew Vanlint said that in the absence of a consistent structure, the quality and usefulness of discharge summaries were highly variable.
“Typical issues included too much or not enough information, heavy use of clinical acronyms and jargon, or inclusion of information not relevant to the GP,” Dr Vanlint said.
“Such issues can have meaningful consequences for patients and GPs alike,” he said.
Dr Vanlint said errors in the continuity of medication, such as discontinuing a medication that should continue, was a primary example.
He said the clear aim of the project was to realign the focus of medical discharge summaries and redesign them with their intended audiences – GPs, patients, family or caregivers – in mind.
Dr Vanlint said the new clinical handover tool was based on the established ISBAR model of communication: Introduction – reason for presentation; Situation/Background – past medical history; Assessment – key issues and management during admission; Recommendations – discharge plans.
He said the format was further refined to include: Investigations – key results; and Medications – changes and rational; and an updated medication list.
