To my knowledge, there is no specific rule – when we first started a hospitalist program many years ago, our CMO made it the standard that whichever physician discharges the patient is responsible for reviewing the record thoroughly and doing the discharge summary......not that we haven't had complaints over the years if a patient was discharged or expired right after a new hospitalist took over, but you have to develop a system that works best for all....
Wendy Mangin, MS, RHIA
Executive Project Director – Regulatory Compliance/Privacy Officer
520 S. Seventh St. | Vincennes, Indiana | 47591
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I do not believe there is a regulation that defines who does one but we have it in our medical record content policy. We decided that the attending of record is responsible (usually is the discharging provider) and if they do not want to do it, they need to find a physician that cared for the patient to do it instead. We leave it up to them to get it covered if they refuse and that seems to be working well. Hope that helps.
The Medicare Conditions of Participation (https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R37SOMA.pdf page 205) states that the record must contain:482.24(c)(2)(vii) - Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care.
Interpretive Guidelines @482.24(c)(2)(vii) All patient medical records must contain a discharge summary. A discharge summary discusses the outcome of the hospitalization, the disposition of the patient, and provisions for follow-up care. Follow-up care provisions include any post hospital appointments, how post hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living.
The MD/DO or other qualified practitioner with admitting privileges in accordance with State law and hospital policy, who admitted the patient is responsible for the patient during the patient's stay in the hospital. This responsibility would include developing and entering the discharge summary.
Other MD/DOs who work with the patient's MD/DO and who are covering for the patient's MD/DO and who are knowledgeable about the patient's condition, the patient's care during the hospitalization, and the patient's discharge plans may write the discharge summary at the responsible MD/DO's request.
In accordance with hospital policy, and 42 CFR Part 482.12(c)(1)(i) the MD/DO may delegate writing the discharge summary to other qualified health care personnel such as nurse practitioners and MD/DO assistants to the extent recognized under State law or a State's regulatory mechanism.
Whether delegated or non-delegated, we would expect the person who writes the discharge summary to authenticate, date, and time their entry and additionally for delegated discharge summaries we would expect the MD/DO responsible for the patient during his/her hospital stay to co-authenticate and date the discharge summary to verify its content.
The discharge summary requirement would include outpatient records. For example:
Survey Procedures @482.24(c)(2)(vii)