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It standardizes the safety, usability, and usefulness of discharge documentation by defining two components: the inpatient discharge summary and a patient directed discharge letter (where considered). The guideline specifies key principles for multidisciplinary completion, plain-English patient communication, accurate and non-duplicative content, appropriate recipient sharing, and timely electronic transmission to nominated GPs and My Health Record with documented consent changes.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/patient-discharge-documentation-guideline-gl2022-005-document-number-and-revision/280682/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/patient-discharge-documentation-guideline-gl2022-005-document-number-and-revision/280682.png","ImageObject",442,249,{"name":88,"@type":89},"Caleb Sterling","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What documents are required for patient discharge under this guideline?","Question",{"text":108,"@type":109},"Discharge documentation consists of two components: the discharge summary and the patient directed discharge letter (additional consideration).","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Who is responsible for completing sections of the discharge summary?",{"text":113,"@type":109},"Each multidisciplinary team member is responsible for completing their section using accurate, relevant information without duplication, abbreviations, or improper alterations of others’ documentation.",{"name":115,"@type":106,"acceptedAnswer":116},"How and when should discharge summaries be shared after discharge?",{"text":117,"@type":109},"The discharge summary is sent electronically if available to the nominated General Practitioner and other primary care providers, unless consent is withdrawn. 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The Guideline aims to ensure a consistent approach to the safety, usability and usefulness of discharge documentation from all NSW public hospitals.  \nDocument type Guideline Document number GL2022_005  \nPublication date 12 April 2022  \nAuthor branch System Performance Support  \nBranch contact (02) 9391 9538  \nReview date 12 April 2027  \nPolicy manual Not applicable  \nFile number H21/241479  \nStatus Active  \nFunctional group Clinical/Patient Services-Information and Data, Records  \nCorporate Administration-Governance, Information and Data  \nApplies to Ministry of Health, Public Health Units, Local Health Districts, Government Medical Officers, Public Hospitals  \nDistributed to Ministry of Health, Public Health System, Government Medical Officers Audience All Hospital Staff;Discharge Planners;Pharmacists;Nurses;Junior Medical Officers  \nSecretary, NSW Health  \nPatient Discharge Documentation  \nGUIDELINE SUMMARY  \nThis Guideline outlines the documentation required when discharging admitted patients from NSW public hospitals. It aims to ensure a consistent approach to the safety, usability and usefulness of discharge documentation from all NSW public hospitals.  \nDischarge documentation is made up of two components, the discharge summary and the patient directed discharge letter (additional consideration) . The completion of discharge documentation does not absolve the need for direct communication between treating clinical teams, patients and carers, it ensures the safe transition of care of the patient. A verbal handover of care is to be conducted whenever clinically indicated.  \nKEY PRINCIPLES  \nThe inpatient discharge summary is a single integrated document which includes input from the multidisciplinary team (MDT) members where available. The discharge summary will be completed on standard electronic or paper medical record templates provided by NSW Health.  \nIt is the responsibility of the discharging clinician to go through the discharge summary with the patient and/or family using health literacy approaches as per the National Safety and Quality Health Service Standard Communicating for Safety Standard. The discharging clinician must ensure that all required information is documented and provided to the patient , their carer/family, nominated general practitioner and all relevant primary care providers as soon as possible or within 48 hours of discharge as per NSW Health Information Bulletin 2020-21 KPI and Improvement Measure Data Supplement ( IB2020 040) .  \nEach multidisciplinary team member is responsible for completing their section of the discharge summary. Information must be accurate, relevant, appropriate, avoid duplication, ensure the use of accepted terminology, and avoid the use of abbreviations.  \nAll multidisciplinary team members contributing to the discharge summary must ensure their name, designation, and signature is provided as outlined in NSW Health Policy Directive Health Care Records – Documentation and Management ( PD2012 069)  \nAll members providing information must not alter the documentation of another provider in the discharge summary without prior consultation. Copying and pasting documents or statements directly from clinical notes written by other members must be avoided unless auto-population is enabled.  \nThe discharge summary must be sent, electronically (if available), to a patient’s nominated general practitioner and other relevant primary care providers unless the patient has withdrawn consent to share the discharge summary. Changes in sharing are to be documented in the clinical record.  \nDischarge summaries are to be shared electronically with a patient’s My Health Record unless the patient withdraws consent. Changes in sharing and reasoning are to be documented in both My Health Record and the clinical record.  \nIt must","cbCainzcr3Ge3fDr","https://ap.wps.com/l/cbCainzcr3Ge3fDr","pdf",678800,20,"English","# Guideline Summary\n## Components of Discharge Documentation\n# Key Principles\n## Responsibilities and Documentation Standards\n## Communication, Sharing, and Consent\n# Revision History","[{\"question\":\"What documents are required for patient discharge under this guideline?\",\"answer\":\"Discharge documentation consists of two components: the discharge summary and the patient directed discharge letter (additional consideration).\"},{\"question\":\"Who is responsible for completing sections of the discharge summary?\",\"answer\":\"Each multidisciplinary team member is responsible for completing their section using accurate, relevant information without duplication, abbreviations, or improper alterations of others’ documentation.\"},{\"question\":\"How and when should discharge summaries be shared after discharge?\",\"answer\":\"The discharge summary is sent electronically if available to the nominated General Practitioner and other primary care providers, unless consent is withdrawn. Sharing should occur as soon as possible or within 48 hours, and consent or sharing changes must be documented in the clinical record and My Health Record.\"}]","Patient Discharge Documentation - Guideline GL2022 005 - Document number and revision | PDF",1789554195,7]