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Documentation Tip of the Week: Discharge Summaries

Posted on Wed, Jul 01, 2015
Documentation Tip of the Week: Discharge Summaries

Our weekly feature of documentation tips for clinicians

The Joint Commission has established standards (Standard IM.6.10, EP 7) outlining the components that each hospital discharge summary should contain:

  • Reason for hospitalization: Chief complaint, including a description of the initial diagnostic evaluation
  • Significant findings: Admission and discharge diagnoses (as well as those conditions resolved during hospitalization)
    • All diagnoses documented in coding based diagnostic language
    • List all possible and probable diagnoses in the discharge summary
  • Procedures and treatment provided: Consults, procedure findings, surgical findings, test results, etc.
  • Patient’s discharge condition: How the patient is doing at time of discharge
  • Patient and family instructions: Includes discharge medications, follow up needed, list of all medications changed and/or discontinued, dietary needs, follow up tests or procedures
  • Attending physician’s signature and date of service
The Discharge Summary should not introduce new information, nor should it conflict with previous documentation substantiated in the record.
 
*Remember that most records are coded and billed within 24 hours of the patients discharge*
Studies have demonstrated a trend toward a decreased risk of readmission when the discharge summary arrives before the outpatient follow-up visit takes place. The study, by van Walraven and colleagues (J Gen Intern Med. 2002; 17:186-192), found a 0.74 relative risk of decreased rehospitalization for these patients.

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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