Health Information Technologies & Processes

Observation Patients, H&P/Final Progress Note

  • 1.  Observation Patients, H&P/Final Progress Note

    Posted 04-12-2018 10:29
    I have a physician arguing that his statement in his H&P on an observation patient “that this will also serve as my discharge summary” is sufficient for his final progress note.


    The rules and regs state a final progress note will be acceptable in place of a discharge summary. While CMS now states every patient is to have a discharge summary (inpatient and outpatient).


    Of course I am arguing an H&P and a final progress note cannot be one in the same.

    Has anyone else ever heard this? He is claiming this was acceptable in a very large health system he was at previously.

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    Deanna Heinrich
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  • 2.  RE: Observation Patients, H&P/Final Progress Note

    Posted 04-13-2018 09:30
    I'd review the issue as to why the H&P and DS was done congruently. Did he not have the H&P done timely and was doing it at time of discharge (Hence the overlap)?

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    Lori Richter
    OneCare EHR Compliance Director
    Catholic Health Initiatives
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  • 3.  RE: Observation Patients, H&P/Final Progress Note

    Posted 04-16-2018 11:12
    ​Joint Commission standard 02.04.01 (Record of Care) states:
    "A discharge summary is not required when a patient is seen for minor problems or interventions.....a final progress note may be substituted for the discharge summary provided the note contains the outcome of hospitalization, disposition of the case, and provisions for follow-up care."

    At my facility we ask for a Discharge Note for stays less than 48 hours (unless there is a complication, death, etc). The discharge note must contain discharge diagnosis, outcome of hospitalization, disposition of the case, and provisions for follow-up care.

    Madeleine

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    Madeleine Sanders,
    Manager of Health Information Services
    Overlake Hospital Medical Center
    Bellevue, WA
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  • 4.  RE: Observation Patients, H&P/Final Progress Note

    Posted 04-13-2018 13:59
    I've had the same argument.  The H&P is required to be prior to surgery and therefore can't include the final progress note which should be completed after the surgery.  In this situation, either the H&P is late or the final progress note is early.

    Good luck.

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    DeAnn Tucker
    Privacy & Security Officer
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  • 5.  RE: Observation Patients, H&P/Final Progress Note

    Posted 04-14-2018 12:46
    When clinicians argued with rules I sometimes repeated the CURRENT regs, and tried using common sense to paint a picture of what could result if they were broken.

    In this case, few docs would argue against a last, brief note before discharge when you needed to update the record on any significant CHANGE from what was going on at time of the H&P. (e.g., Patient was found dead by nurse, patient left AMA, patient's family got angry and insisted on transfer elsewhere, patient fell and broke bone and is asking for attorney... ) If they acknowledge that would be needed, then the corollary is: you must also document the negative. You need to enter an even-more-brief last note to confirm that there had been no significant change in patient's condition.

    If a doc is easily spooked by the spectre of litigation, throw in that the absence of that last, brief note saying "nothing has changed, and she is being discharged," leaves a vacuum of up to 22 hours in the record -- which could be filled by any wild allegation by patient or family that "we kept telling people that his x and y were just getting worse and worse and the Doctor never even noticed!"

    (File under "worth a try")

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    Ruth Czirr
    Retired Privacy Officer / Compliance Officer
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