Communication with GP's

We keep GP's fully informed about their patient's care through our effective discharge process.

On discharge from in-patient care

An in-patient discharge note will be completed on the day of discharge and signed by a member of the service user's care team. This will be faxed or e-mailed to the practice on the day of discharge. It will contain:

  • Diagnosis / Care Cluster
  • Discharge medication plan (supply provided on discharge and repeat prescription arrangements)
  • Contact details of the care co-ordinator
  • How to access help out of hours or in a crisis including telephone numbers
  • Arrangements for seven day follow up
  • Relapse and risk management plans
  • Plans for promoting engagement and concordance with care and treatment
  • Contingency plan including arrangements for non-attendance.
  • A copy of the CPA / Care plan and risk assessment will be sent to the practice by post or e-mail within 3 working days.

On transfer or discharge

When a service user is discharged or transferred from one of our community services, an updated Care Programme Approach CPA / Care plan will be sent to you as the service user's GP. It will set out the completed and continuing care / treatment needs. If the service user was transferred to another service, either within or external to the Trust, the details of the receiving service will be included in the CPA/ Care plan.

Following review

  • A copy of the CPA / Care plan will also be sent to you following any review. A review often coincides with the discharge of an individual.
  • General Practitioners are invited to CPA / Care plan review meetings for all service users being managed within secondary care.

Discharge from Inpatient stay

Discharge will be planned from the point of admission in conjunction with community services to identify potential needs on discharge.

Discharge will be co-ordinated by the care co-ordinator and inpatient named nurse with the involvement of the Home Treatment Team if appropriate.

As the service user's GP we will provide you with information about the person's onward care, treatment and medication.

All service users who have had a period of inpatient care will be given a follow-up by a member of the mental health team in the community within seven days of discharge, including those who take their own discharge. The discharge care plan will include:

  • Diagnosis / Care Cluster
  • Discharge medication plan (supply provided on discharge and repeat prescription arrangements)
  • Contact details of the care co-ordinator and how to access help out of hours or in a crisis including telephone numbers
  • Arrangements for seven day follow up
  • Relapse and risk management plans
  • Plans for promoting engagement and concordance with care and treatment
  • Contingency plan including arrangements for non-attendance.

 

 

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