Its time to talk: Medicines information in the Discharge Summary - - PowerPoint PPT Presentation

Explaining changes on the discharge medicines list

It’s time to talk: “Medicines information in the Discharge Summary” Presenter

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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 seizure-

first one.

• Patient commenced on Phenytoin
• Required to remain in hospital for an extended period due to sub-

therapeutic 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 (unpublished)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• Discharge medication list: “Aspirin” (unpublished)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
• Accurate
• Legible
• 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

• f 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