Information Governance & Standards

1.  Discharge Summary COP

Posted 6 days ago
  |   view attached
​​I have come across a letter from Lynn Thomas Gordon to CMS asking for clarification on the "discharge summary for every patient" regulation.   The letter is dated 8/5/2016.  I was wondering if AHIMA ever received a response from CMS on this matter.  I have attached letter.

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Stacey Goodenough
Manager of Medical Records / Privacy Officer
Wayne Memorial Hospital
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Attachment(s)



2.  RE: Discharge Summary COP

Posted 3 days ago
If we haven’t received a response, is someone able to send a follow up letter?

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Deanna Heinrich
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3.  RE: Discharge Summary COP

Posted 2 days ago
Hi Deanna and Stacey,

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

https://www.regulations.gov/document?D=CMS-2016-0095-0001.

 

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,



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Kristi Fahy, RHIA
Manager, Informatics, Information Governance, and Standards
AHIMA

kristi.fahy@ahima.org
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4.  RE: Discharge Summary COP

Posted 2 days ago
Discharge summary for all patients is a current regulation:


482.24 (c)(4)(vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care, implemented 6-7-13.

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Deanna Heinrich
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5.  RE: Discharge Summary COP

Posted yesterday

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.



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Stacey Goodenough
Manager of Medical Records / Privacy Officer
Wayne Memorial Hospital
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