Health Information Technologies and Processes

Discharge summary - deficiency tracking

  • 1.  Discharge summary - deficiency tracking

    Posted 19 days ago
    I work at a facility that gets a handful of patient transfers from another facility. We currently are using epic and the system will auto generate a deficiency to the provider who wrote the discharge order. The HIM department I Work for tracks deficiencies for both of these hospitals. We get a bunch of declined deficiencies from the provider with comments of "this patient was transferred no summary needed".  I was just wondering if there were any other HIM staff tracking deficiencies for more that one facility and how you are handling these issues with transfers? It has always been our practice to ask for a note for any stay longer than 2 days.

    Thank you  in advance,
    Carol

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    Carol Vergari
    Analyst/Programmer Sr
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  • 2.  RE: Discharge summary - deficiency tracking

    Posted 19 days ago

    Hi Carol,

     

    A discharge summary is needed for stays greater than 48 hours or when a patient expires, regardless of time. Especially when patients get transferred, they should always have a discharge summary sent to the receiving facility.

     

    Thanks,

    Karla

     






  • 3.  RE: Discharge summary - deficiency tracking

    Posted 19 days ago
    I think the transfer confuses our providers. Once we tell them the 48 hour rule they end up satisfying the deficiency. It's the back and forth that can frustrate the deficiency analyst on my team. I think our facility needs to touch base one documentation requirements at resident orientation.

    Thanks,

    Carol


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    Carol Vergari
    Analyst/Programmer Sr
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  • 4.  RE: Discharge summary - deficiency tracking

    Posted 19 days ago

    Education is definitely a good place to start! Good luck! We know all about the frustration piece.


    Karla