Health Information Technologies and Processes

Discharge summary responsibility

  • 1.  Discharge summary responsibility

    Posted 07-16-2019 22:19
    In an inpatient hospitalization where one physician admits the patient, and another physician discharges the patient, is there an official guideline that dictates who is responsible for doing the discharge summary? The admitting provider or the discharging provider?

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    Christina MerleBS,MS,RHIA,CDIP,CCS,CCDS
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  • 2.  RE: Discharge summary responsibility

    Posted 07-17-2019 05:06
    I believe there is no such guideline. Attending/Discharge Provider will dictate the discharge summary..

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    Bobbili Shankar
    Medical Coder
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  • 3.  RE: Discharge summary responsibility

    Posted 07-17-2019 07:41

    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

     

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  • 4.  RE: Discharge summary responsibility

    Posted 07-17-2019 07:48

    Hi Christina,

     

    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.


    Thanks,


    Karla

     






  • 5.  RE: Discharge summary responsibility

    Posted 07-17-2019 17:45
    ​Thanks all for the responses! After a little more digging, I found this to be helpful, at least in citing an official source:

    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:

    • The outcome of the treatment, procedures, or surgery;
    • The disposition of the case;
    • Provisions for follow-up care for an outpatient surgery patient or an emergency department patient who was not admitted or transferred to another hospital.

    Survey Procedures @482.24(c)(2)(vii)

    • Verify that a discharge summary is included to assure that proper continuity of care is required.
    • For patient stays under 48 hours, the final progress notes may serve as the discharge summary and must contain the outcome of hospitalization, the case disposition, and any provisions for follow-up care.
    • Verify that a final diagnosis is included in the discharge summary.


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    Christina MerleBS,MS,RHIA,CDIP,CCS,CCDS
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  • 6.  RE: Discharge summary responsibility

    Posted 07-18-2019 13:44
    Christina,

    The Conditions of Participation is what my former facility uses for guidelines as they are a huge teaching facility. My current facility is much smaller and a rural health provider so it's the responsibility of the discharging physician to complete the discharge summary since it was their decision to discharge the patient. The guidelines you create for your organization will truly depend on what workflow works best for everyone involved.

    Thanks,

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    Glenda Rakes
    HIM Director
    Northern Montana Health Care
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  • 7.  RE: Discharge summary responsibility

    Posted 07-19-2019 14:55
    You might also check your Medical Staff Rules & Regs.  Sometimes responsibility is defined there.

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    DeAnn Tucker
    Him Director
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