Yes, a Discharge Summary must be completed for all inpatients, including those deceased or transferred out.

No, Day Surgery patients who are not admitted as an inpatient under a Physician’s order do not require a Discharge Summary; these patients will still require an OR/Procedure Note.

Yes, a Discharge Summary must be completed, as an inter-facility transfer is considered a discharge from UHN and admission to the other site.

Standard practice at UHN for any dictation starting with “Dear Doctor” is considered to be a letter. Discharge Summaries have specific standards and guidelines, and should not start with “Dear Doctor”. Please refer to Policy 3.10.002 and CPSO Policy 4-12.

Standard practice at UHN is to create each note separately, specific to their guidelines and templates. This is in alignment with the UHN Chart Completion by Clinician Policy 3.10.002 and CPSO Policy 4-12.

At UHN, a Discharge Summary is completed electronically or by dictation, depending on the Physician Service. Please consult the Attending/Most Responsible Physician for the patient or Chief Resident to determine the appropriate protocol to be followed.

A good Discharge Summary is 2-3 pages in length and only contains information needed to ensure continuity of care after a patient leaves UHN. For guidelines on information to be included in a Discharge Summary, please visit Best Practices.

The Discharge Summary template can be viewed on a computer or smartphone, downloaded or printed from the Guides section of this website, under UHN Discharge Summary Template

The template was put together based on recommendations from the Toronto Central LHIN, input from Primary Care Providers, and trial by UHN Clinicians. Following the template to dictate your note will ensure that Primary Care Providers receive relevant, concise, and value-added information to ensure timely and appropriate follow-up care.

Electronic Discharge Summary notes will appear in EPR immediately upon completion. Dictated Discharge Summary notes will appear in EPR once they have been transcribed. A list of all outstanding Discharge Summaries for which you are the assigned MRP is available in the Clinical Portal (CliP) application.

Yes, MRPs have the option to review/edit notes dictated by their Residents/Students prior to sign-off, via the Clinical Portal (CliP) application; contact ChartCompletionUHN@uhn.ca to have this set up for you.

• Electronic Notes: Log in to the eNotes application via EPR and click on the completed Discharge Summary for the appropriate patient visit; make the appropriate changes and re-save/submit.

• Dictated Notes: Log into the Clinical Portal (CliP) application, select the Discharge Summary from the completed work queue, make the appropriate changes.

Discharge Summaries that have been corrected will be re-sent to the designated recipients.

Once a Discharge Summary has been completed electronically or a dictated note has been transcribed, the following occurs:

• If an accurate fax number is available for the intended recipient Provider, the Discharge Summary will be faxed within 30-minutes of completion

• If an accurate fax number is not available, the report is printed out at Health Records Services, processed by UHN Mail, and manually mailed out to the recipient via Canada Post

Please complete the EPR Provider Add/Change/Deactivate Request Form under Forms on the Corporate Intranet Site. UHN Data Security will notify you when the change has been completed (approximately 24 hours); upon notification, update the patient record and/or Discharge Summary with the new/updated Provider.

The Primary Care and Referring Provider documented on the patient’s face sheet in EPR are automatically sent a copy; only other appropriate individuals in the circle of care should be added to the CC To field.
To send a note to a newly added recipient you must re-save/submit the note; this will result in recipients that were previously documented receiving an additional copy of the note.

 How much time does a Clinician have to complete their notes?

 When does the 48-hour timeframe for chart completion begin?

 When is a note (Discharge Summary/OR Note/Transcription Query) considered complete?

 Why is it important to complete notes within the 48-hour timeframe?

 Do the timeframes in the policy refer to business hours/days?

 Does the Clinician get an additional 48 hours to complete a Discharge Summary if he/she was assigned as the Most Responsible Physician (MRP) after another Physician notified Health Records Services that they were wrongly assigned as the MRP?

 What happens if a note is dictated within 48 hours, but is not transcribed until after 48 hours?

 Where can Chart Completion reports be viewed?

 Who is able to view a Physician’s Chart Completion Reports?

 Do the timeframes in the reports refer to business hours/days?

 How can overdue items in the Chart Completion Reports be viewed?

 What types of notes are captured in the Transcription Query report?

 What should the MRP do if information in their Chart Completion Reports is incorrect?

 Will cross-listed Physicians' information appear on all Division/Department/Program level reports to which the Physician belongs?

 Is it possible to obtain Chart Completion reports for a custom date range?

 Will Physicians be notified of new and overdue Chart Completion items?

 What should the Most Responsible Physician (MRP) do if he/she receives a notification to complete a Discharge Summary for a patient for whom he/she is no longer the MRP?

 Why does a MRP still receives a Chart Completion notification when he/she has already completed the Discharge Summary?

 When should Health Records be contacted during the chart completion process?

 How are privileges re-instated after a suspension?

 Who is considered the Most Responsible Physician (MRP) at UHN?

 Who should be documented as the MRP/Attending Physician for patient transfers between Surgery/Intensive Care Units (ICUs)?

 Who should be documented as the MRP/Attending Physician for patient transfers between Surgery/General Internal Medicine (GIM)?

 Who is documented at the MRP/Attending Physician if there are multiple Surgeons involved in providing care for the patient?

 If a Physician needs to transfer MRP responsibility to another Physician, what steps does he/she need to complete?

 What should be done if a Physician is wrongly identified as the MRP during the course of stay for a patient?

 What should the MRP do if he/she notices that he/she has been wrongly identified as the MRP post-discharge of the patient?

 Should the patient be informed of any change of their MRP?

 What happens to MRP responsibility for after-hours and weekend coverage?

 Who is the MRP for an inter-facility patient transfer?