While the deadline for Australian hospitals to devise a plan for uploading discharge summaries to My Health Record has passed, there’s still time to implement a system that not only ensures you comply, but do so with ease.
At MasterCare, we’ve worked closely with the Australian Digital Health Agency (ADHA) to make sure our discharge summary solution is 100% compliant to their framework, meeting all the requirements set out in the Australian Commission on Safety and Quality in Health Care’s National Guidelines for On-Screen Presentation of Discharge Summaries.
Our solution is custom engineered for the Australian healthcare ecosystem and specifically designed to help clinicians generate comprehensive discharge summaries quickly and efficiently.
A digital solution for today … and for the future
Up until now, it’s been acceptable to upload handwritten discharge summaries. However, that will no longer cut it under the new framework, which requires uploaded documents to be clinical document architecture (CDA) compliant.
As a result, hospitals may need to revisit the way they upload clinical documentation.
MasterCare’s software automates the creation and distribution of digital discharge summaries, reducing the likelihood of manual data entry errors and miscommunication. As one of only three systems on My Health Record’s conformance register, our secure messaging protocols mean discharge summaries can be directly uploaded to My Health Record.
Capture comprehensive care details in one solution
Discharge summaries are more than a nice-to-have, potentially making or breaking patient outcomes after discharge. For the patient’s GP, for example, discharge summaries provide critical information about the episode of care, including key details such as medication changes or follow up requirements.
Should the patient be readmitted urgently or go to another hospital, it provides vital information for treating clinicians.
MasterCare+ begins capturing details from the moment patients are admitted, or even beforehand with our Digital Front Door. With all the details about an episode of care conveniently located in your patient administration system, it’s easy to generate a comprehensive summary of everything that has happened during their stay – and key things that need to happen post-discharge.
Convenient for clinicians
With MasterCare+, clinicians don’t need to find space to sit down and write a discharge summary, nor waste time scanning it in. They can simply fill it out on a computer or iPad (or even their phone), saving time and freeing them up to focus on what they do best – caring for patients.
With information stored securely in the cloud, there’s no need for clinicians to remember every detail about a patient’s care episode either. They can simply access these details on the go, whether they’re walking down the ward, at the bedside, or in the nurse’s station.
User-friendly experience
MasterCare+ is incredibly easy and intuitive to use. Follow these steps to create a discharge summary and upload it to the My Health Record system.*
1. Log on to MasterCare+ and navigate to a patient’s profile using their unique identifier (e.g., name, date of birth, or medical record number). If the episode has already been locked, simply access the “Ready for Discharge” list found on the MasterCare+ landing page.
2. After obtaining consent from the patient to upload to MHR and entering it in the system, and ensuring the patient has a verified Medicare number, toggle to the Episode and Encounters tab within the patient’s profile.
3. Input required details to generate the discharge summary as per the ADHA requirements:
• Enter patient details (these will auto-populate based on the patient’s record).
• Admission and discharge dates.
• Reason and location of admission.
• Care team assessing the patient and the completion of their assessment.
• Diagnosis, clinical summary obtained, medications prescribed/ceased, and recommendations instructed (MasterCare+ integrates with MIMS and SNOMED to generate relevant clinical codes).
• “Discharge to” location and the “Discharge Staff” (staff member needs to have an HPI-I in order to have uploading permissions).
4. Enter optional data:
• Add any relevant clinical notes, which can be internal communications between staff members, relevant to the episode/encounter.
• Imaging results, or lab reports that are necessary for continuity of care.
• Clinical documents, which can be scanned and inserted into the patient’s file (with a simple drag and drop or by attaching a file).
5. Save and lock the discharge summary – a discharge summary can be unlocked to make amends at any time by people with certain permissions.
To ensure the upload to MHR meets ADHA recommendations, the discharge summary has to be signed by a medical/registered staff member with an HPI-I number.
Once signed, the template of the discharge summary will be generated and can be either automatically uploaded to MHR or manually uploaded by any of your staff, as per your required configuration.
A copy of the discharge summary will be found in the patient clinical documents, which can be printed or electronically sent to relevant healthcare professionals.
To learn more about how MasterCare+ can support you with compliance, book a demo of our hospital solution or contact our sales team.
* Specific instructions may vary depending on your organisation’s configuration, so consult our support team/SME or your Account Managers for guidance. User guides are also available to familiarise you with our platform and its different capabilities/modules.
