Information Governance & Standards

Discharge Summary COP

  • 1.  Discharge Summary COP

    Posted 04-13-2018 15:27
      |   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 04-16-2018 09:22
    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 04-17-2018 10:38
    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 04-17-2018 19:13
    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 04-18-2018 08:11

    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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  • 6.  RE: Discharge Summary COP

    Posted 04-25-2018 14:26
    ​I am trying to figure out the same thing,  Are discharge summaries required for observation patients and patients that go from surgery to observation?  The way the Regs read it sounds like all records includes these types of patients also.  I'd like to have confirmation on that
    to give to our medical staff.

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    Cheryl Ervin
    Director, Health Information Services
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  • 7.  RE: Discharge Summary COP

    Posted 04-30-2018 15:51

    ​There was a revision to the SOM to include an Appendix.  Appendix A, provides interpretive guidelines for 42 CFR 482.43 - Discharge Planning.  There is a statement that indicates that under regulation, hospitals are required to have a discharge planning process for all inpatients and not required for outpatient.  See page 7 "for more information section" on post-planning for certain categories, including outpatient.

    Appendix A can  be retrieved from:
    https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-32.pdf













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    Theresa Victor, RHIA
    Compliance Officer

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  • 8.  RE: Discharge Summary COP

    Posted 05-01-2018 22:48
    The regulation however is dated 6-7-13 which is after that was posted. Why does CMS make everything so complicated?!

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    Deanna Heinrich
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  • 9.  RE: Discharge Summary COP

    Posted 05-02-2018 08:27
    Edited by Stacey Goodenough 05-03-2018 12:26

    Can we link the discharge planning guidance to the discharge summary requirement?  To me they seem to be two distinct items.  I guess that is where I am getting hung up.  DC Planning is under 482.43 and the discharge summary is under 482.24.  To me they are two separate requirements, particularly since the SOM for discharge summary references outpatient requirements. 



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    Stacey Goodenough
    Manager of Medical Records / Privacy Officer
    Wayne Memorial Hospital
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  • 10.  RE: Discharge Summary COP

    Posted 17 days ago
    ​I have an observation chart in front of me that has an H&P which gives the "impression" but says nothing about discharge, just ends by stating what the workup is going to be. There is an order written the states patient may DC to home if labs are .......... Is that good enough to not have to request a discharge summary be done?


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    Cheryl Ervin
    Director, Health Information Services
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  • 11.  RE: Discharge Summary COP

    Posted 14 days ago
    ​I don't know if this will be helpful or not, but in our organization our observation patients do not have a separate discharge summary unless they are here for more than 48 hours. When the patient is put into CDU, the provider begins a CDU document that contains the beginning information of the stay all the way to the discharge of the patient. This is the document that we use to code from because it contains all admitting DXs and all of the discharge DXs along with final instructions/recommendations etc. In our policy we only do a discharge summary if the patient is admitted for inpatient surgery and as an inpatient stay. Our CDU and outpatient surgeries do not require an actual discharge summary. We typically add the discharge assessment to the CDU or surgery outcome notes.  Below is verbiage of our policy.

    1.1 The discharge information provides continuity of care for future caregivers. It is

    most often found dictated or entered as electronic documentation in the medical

    record.

    1.2 Discharge information includes: the reason for hospitalization, any procedures

    performed, description of the care, treatment and services given to the patient,

    document the course and results of treatment, the patient's condition at discharge,

    disposition at discharge, any information given to the patient and family, the

    outcome of treatment, procedures or surgery, and the provisions for follow-up care.

    1.3 A discharge summary shall be documented on all medical records of patients

    hospitalized over 48 hours.

    1.4 A final progress note will suffice when the patient has been treated for minor

    problems or interventions and hospitalizations less than 48 hours.

    1.5 If a patient is transferred to a different level of care within the hospital and

    caregivers change, a transfer summary is acceptable. This is usually documented

    as a progress note.

    1.6 A dictated discharge summary is not required for normal newborns with

    uncomplicated deliveries.



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    Sandra Furlow
    United Regional Health Care System
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