Hospital Discharge Summaries

what is a discharge letter 

a letter that communicates necessary information about the patient’s admission to primary care 

• reason for patient’s admission

• what were they diagnosed with

• how were they treated 

• investigation that were undertaken

• follow up arrangements

• requests for primary care 

what is a discharge prescription 

• has all the medications that we want the patient to continue taking after leaving the hospital (medicines that the patient is being discharged on

• sometimes called TTO (to take out) /TTA (to take away) /TTH (to take home)

what is a discharge summary

• all patients who leave hospital are provided with a discharge summary, which contains 

  • discharge letter

  • discharge prescription (TTO/TTA/TTH)

what is the inpatient journey 

admission → inpatient management → discharge 

what is the discharge process

1. patient is declare medically optimised for discharge

2. a discharge letter is written and an appropriate prescriber writes the discharge prescription

3. a pharmacist screens the discharge prescription

4. medication is dispensed against the discharge prescription

5. the discharge letter, prescription and dispensed medicines are given to the patient

what is the importance of discharge summaries and checking discharge prescriptions

there is a risk of miscommunication of a patient’s medication when moving between care providers

• patients can have changes to their medication after admission

• patients can have their medicines discontinued drug their hospital stay

• patients can be prescribed new medicines at discharge

what are the purposes of the discharge prescription

• instructions to supply medicines to the patient 

• communication with primary care about what medicines the patient should be taking 

• supporting effective communication across care interfaces (one place to another) is the main function 

  • the patient receives a copy as well as the patient’s GP

  • the list of medicines represents everything we want the patient to take once they have left hospital 

what is the role of pharmacists in the discharge process

screening of discharge prescriptions, which help to: 

• improve quality and accuracy of discharge prescriptions 

• identify and rectify prescribing errors 

what needs to be considered when screening a discharge prescription 

• legality 

• accuracy (in terms of transcription from the inpatient chart)

• clinical appropriateness 

(inpatient chart is an instruction for nursing staff to administer medication to a patient whilst they’re in hospital → pharmacist needs to make sure the chart is accurate and up to date)

example discharge summary