Discharge report from secondary care
Summary of an episode of care to a GP or other specialist, including the transferral of relevant medical information
Purpose and Business Need
For the referral of a patient, all relevant medical information should be accessible by the healthcare professional who will be responsible for further treatment.
EHDS Context
Primary use
Health Information Domain and EHDS Priority Data Category
- Patient coordination
- Referral letter
- Discharge report
Context
After having received specialised treatment in a hospital setting, the patient is released. Episode-based patient summary information (with a focus on the treatment of the specific disease) is prepared by the attending physician in the hospital. If appropriate, the information is transferred to the primary care physician and medical specialists.
Participants
- Patient
- HCP in secondary care (specialist)
- HCP in primary care (GP)
Functional process flow
- Specialist creates an automatic discharge letter in his EHR, in editable form
- Specialist edits the text treats the patient and patient visits GP. The GP decides to refer the patient to a specialist
- The GP selects the patient in his / her healthcare information system (HIS)
- The GP writes a referral letter.
- The GP selects a specialist and sends the referral letter to the specialist