How to ensure the discharge summary is complete

This month, I would like to focus on one of the most important elements of documentation: the discharge summary. The discharge summary serves as a communication tool for primary care providers, summarizes the hospital course for future reference, and is a primary source of information for coding and billing.

Dr. David Chand

Dr. David Chand

Despite its multiple uses, discharge summaries often lack the core elements that allow them to serve such functions.

I think we have all had the experience of reading a discharge summary and, when finished, still feel unable to understand what truly happened during the patient’s hospitalization.

A recent survey of physicians and hospitalists identified 7 clinical elements that were considered essential by more than 75% of respondents:

  • dates of admission and discharge
  • discharge diagnoses
  • brief hospital course
  • discharge medications
  • immunizations given during hospitalization
  • pending laboratory or test results
  • follow-up appointments (Coghlin et al., Hospital Pediatrics, Volume 4, Issue 1)

I believe there are some additional challenges related to the use of the EMR, such as the cut-and-paste function and embedded smart phrases, which lead to disjointed, convoluted summaries.

Issues with the discharge summary become even more prominent when a patient changes services, requires intensive care, or when an issue that’s outside the specialty of the primary team occurs. Although the summaries are often written by others, we all have the ultimate responsibility to make sure they contain all necessary elements. We need to work together toward complete, accurate, concise and timely communication.

The Clinical Documentation Improvement (CDI) team would like to share the following information about the discharge summary from a regulatory standpoint. The importance of the discharge summary cannot be overemphasized. It should be a reflection of the major events of the hospital stay.

“CMS encourages providers to ensure all entries are consistent with other parts of the medical record” (MLN Matters article SE 1028). Any diagnosis that potentially could influence the course of treatment should be documented. If a significant diagnosis is documented in the progress notes, operative notes, H&P and/or procedure notes, it needs to be documented in the discharge summary to meet CMS and Joint Commission criteria.

The discharge summary “is considered complete when it identifies the patient, justifies the care, treatment and services received, documents the course of care and results of care, treatment and services, and promotes continuity of care among providers. The record should reflect the patient’s condition upon arrival, an initial evaluation, preliminary diagnosis, document tests performed and their results, document procedures performed and their findings, document therapies and the response to treatment, complications of treatment, final diagnosis and condition, medications and management plans at discharge” (JCAHO, 482.24 (c) (2) (vii, viii).

About David Chand, MD

Dr. David Chand is a pediatric hospitalist and Lean Six Sigma deployment leader at Akron Children's Hospital. He has a special interest in eliminating waste in healthcare and uses Lean Six Sigma principles to improve patient care and efficiency.

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