Health Information Technologies and Processes

Newborn combined H&P and DC Summary

  • 1.  Newborn combined H&P and DC Summary

    Posted 23 days ago
    We have a policy that permits a combined H&P and DC Summary for visit less than 24 hours.  It must meet timeliness requirements for H&P and should have required content for both H&P and DCS included.

    Was wondering if there was experience out there for doing this with normal newborns.  Short visits, going home, no significant issues.

    Looking for ways to reduce our delinquency for some of these requirements but also make it easier for the providers.



    Marianne Dailey
    Director Him & Privacy Officer

  • 2.  RE: Newborn combined H&P and DC Summary

    Posted 22 days ago

    Hi, yes we do that. Our providers use a newborn/discharge template document within our EMR.



  • 3.  RE: Newborn combined H&P and DC Summary

    Posted 21 days ago

    We always combined, particularly when there were no complications.


    Lynn Boyes, RHIT

    Health Information Management Director,

    HIPAA Privacy Officer

    7010 S. Yale Ave | Tulsa, OK 74136 918.236.4135 direct line

    918.499.1598 fax

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  • 4.  RE: Newborn combined H&P and DC Summary

    Posted 20 days ago
    Hi, do you manually clear the chart as complete or can the EMR manage it?

  • 5.  RE: Newborn combined H&P and DC Summary

    Posted 22 days ago
    I have managed departments where we had a short stay discharge summary for stays less than 24 hours. In my opinion this propagated sloppy and incomplete documentation.  And I would not allow a combined document.  A strong line needs to be drawn for providers.  You also open the door for requests to combine other reports.  Data is everything in healthcare today.  When combining reports and allowing short forms we short change the patient by allowing documentation that is less likely to meet bylaws, which are based on regulatory requirements.  
    We waited until we had a Chief of Staff and Administration that understood the importance of complete documentation, and changed our bylaws to disallow short stay forms.