The letter that AHIMA submitted to CMS was in response to the propose rule: Medicare and Medicaid Programs: Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care
CMS does not typically send direct responses to AHIMA or other organizations submitting responses for proposed rules. The Final rule was never issued so there were no further actions or responses in regards to the topic.Thanks,
Thank you. I was hoping for a little more clarification on the COP SOM since it does indicate that a discharge summary is required for "all patients"
"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 discharge summary requirement would include outpatient records" @482.24(c)(4)(vii)I am trying to re-write our medical records rules and regs and give clear direction to our medical staff as to what MR will review for based on state and federal guidelines. Outpatient accounts such as SDC's that stay for continued observation, mom's that don't deliver, chemotherapy visits etc.... currently may not meet the above requirement at our facility. There are some clinical persons that believe the DC instructions are satisfactory to meet the above requirement. I'm not sold on that theory. If you or anyone has additional insight, I would love it. Thanks again for researching.