Outpatient letter
Summary
- Care records
- Continuity of care
- Demographics
- Information governance
- Key care information
- Patient communication
- Pharmacy, Medicines and Prescribing
- Referrals
- Tests and diagnostics
- Community health
- Hospital
- Mental health
Documentation
Due to the rise in the number of specialist services delivered out of hospitals, well-structured outpatient letters have become increasingly important to provide good care. Outpatient letters are the main method of contact and communication between hospital staff and GPs, and are often the sole record of the consultation held by the outpatient department and hospital. Best practice for most outpatient letters is writing directly to patients.
This standard allows clinical information to be recorded, exchanged and accessed consistently across care settings.
About this standardThe Outpatient Letters Standard is designed to improve and standardise the content of outpatient letters so that professionals, patients and carers receive consistent, reliable, high-quality information that can be shared between them all. This project supports NHS Digital and NHS England’s interoperability efforts. Potential benefits from having interoperable electronic outpatient letters, which reflect the requirements of patients, carers, people being supported in care services and care professionals, are significant. They include:
Improved patient safety by:- having information which is needed for safe continuity of care to be available on a timely basis. avoiding transcription errors when medication information is electronically transferred to the GP record (following clinician review), without the need for re-entry.
- having consistent and timely information (including medications, diagnoses, procedures and allergies) transferred to all relevant care professionals and their GP practice.
- providing patients with legible up to date information about their outpatient attendance.
- people being able to access to their records online.
- increased efficiency for multidisciplinary teams by providing structured and coded information on diagnoses, procedures and medications which can be reused for new ways of working as teams develop and expand.
- removing the need to develop and design content locally, by using national standards reducing the duplication of recording.
- re-use in clinical audit and research.
- increased ability to measure and improve actual patient clinical outcomes rather than process outcomes.
A hugely increased opportunity for future development of patient- led care by ensuring interoperability between multiple systems, including personal health records.
Scope- Adult discharge from outpatient health services;
- Communication back to the GP and patient.
- Discharge from non-mental health inpatient stay – refer to the eDischarge Summary Standard
- Discharge from mental health inpatient stay – refer to the Mental Health Inpatient Discharge standard
- Discharge from emergency care – refer to the Emergency Care Discharge Standard
- Transfer between hospitals – although much of the content may be appropriate
- Information not pertinent to the patient’s outpatient attendance
The Outpatient Letters Standard operates by ensuring that all relevant information is recorded and shared in a structured and coded format. This facilitates seamless communication and continuity of care across different healthcare settings.