How to complete a discharge summary on EPR- Guide for Clinicians
1. Open the Discharge Tab
- Navigate to the “Discharge” MPage at the top of the EPR screen.
2. Complete the Clinical Summary
- Select Clinical Summary from the left-hand menu.
- This section may already be populated if it has been updated throughout the admission.
3. Update the Diagnosis / Problem List
4. Add Procedures
- Go to the Diagnosis and Procedure tab (blue menu on the left). ( See video in section 3)
- Ensure all relevant procedures performed during the admission are recorded.
5. Document GP Actions and further investigations
- Any appropriate tasks or follow-up required from the GP should be entered in the “Plan and Requested Action” box. GP is not expected to chase investigations requested by you or your consultant or arrange hospital appointments. This is to be done by hospital team if necessary post discharge.
- Ensure all requested outpatient investigations are documented and actioned appropriately
6. Do Not Delete Columns
- Do not remove any sections from the summary—other MDT members complete these fields.
7. Complete Resuscitation Review
8. Book Follow-up Appointments
- Use Request/Care Plans → place an order for Post-Admission Appointment.
- Confirm the receiving department has agreed to the follow-up before adding it.
9. Complete Discharge Medication.
- Navigate to the Discharge Medications heading and click on the “discharge” button. All orders on this page will need to be reconciled using the columns available
- Do not use the green triangle “continue after discharge”, as this is a workflow not used in the UK.
- Pill bottle – Medications to be continued on discharge. Ensure any controlled drugs are completed with quantity of medications to be provided in words and in figures.
- Red square – any medications that do not need to be continued after discharge.
- Please ensure 28 days supply of longterm medication and remaining duration of the course for the other medication e.g.antibiotics.
10. Add Your Details
- Under Person Completing Record, enter:
- Your full name, Grade, GMC number, Bleep number
11. Generate and Submit the Discharge Letter
- Select Inpatient Discharge Summary from the left column.
- Allow the document to load with all updated sections.
- Click Submit (bottom right).
12. Making Changes After Submission
- Amend any section by updating the relevant tab in the Discharge MPage.
- Refresh the discharge summary afterwards to pull through changes (see video).
13. Forward to Responsible Consultant
- Open the final discharge summary via the Documents tab → Modify.
- At the top, select Forward Person and add the consultant’s name
Please follow this process to discharge inpatient as deceased.
Appendix:
- Detailed SOP for discharge letter completion on EPR.
- Documenting TTO Medication.
- Ordering a Follow up after inpatient stay.
- Coding made easy and diagnosis documentation.
- Discharging inpatient as deceased.
Mohammed Sahir, Zehra Irshad, Feras Izzat, Asad Ali.