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“Some doctors consider discharge forms as ‘quick jobs’ and are keen to clear them out of the way”


responsible for transferring the ongoing care from secondary to primary care. You are accountable for the information you provide to the community doctor and any potential harm that may occur if you omit relevant information.


MDDUS has dealt with numerous cases where the misreading of a


discharge form, or absence of relevant information, has resulted in patient harm. An example includes when a medication has been stopped, but no reason or explanation has been recorded on the discharge form. As a result it is not noticed by the GP who may have received a pile of other discharge summaries that same day. The patient could then receive a repeat prescription from their local practice including the omitted medicine. Similarly, we have encountered cases in which patients have not been


followed-up in the community following a new diagnosis or abnormal result because it has either been omitted from the discharge form or was illegible.


Although you may anticipate the GP will receive more detailed


correspondence from the hospital after your discharge form, unfortunately this often either does not take place or is lost.


Getting help Many hospitals have their own proforma and guidance notes to complete


discharge forms. Your hospital may also use an electronic system, which should reduce the risk of legibility difficulties, although you should be mindful of the additional risk of predictive text errors and ignoring pop- up messages about drug interactions. If you are unsure how to complete a particular discharge form,


consider consulting a senior team member to make sure you have included everything that the patient’s GP needs to know. The ward pharmacist and nursing staff are also valuable sources of information and support. Help is also available from external bodies such as the British Medical


Association or the Royal College of Physicians, which has useful guidance on record standards on its website (tinyurl.com/h2cq6t9). Section four of the RCP guidance provides suggested headings for discharge forms (both paper and electronic) and you may want to check your own form against this checklist. It also provides examples of what information, including relevant positive and negative findings, should be contained within each heading. If you find the boxes within your discharge forms are too small to fit all the necessary information, continue on an additional form. You should then number each form and indicate the total. This is much better than writing in a microscopic text to include everything on one form, which may be barely visible at all on the third carbon copy.


In summary You have numerous demands on your time with colleagues asking you to do things as fast as you can to help them to do their job. In each case, try to make decisions that you are happy with, weighing up the need to provide a detailed discharge form with other clinical obligations and the wider needs of the hospital.


Dr Naeem Nazem is a medical adviser at MDDUS and editor of FYi


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