jdibble
True Blue
I have been trying to find what documentation is required in a Discharge Summary and have been not getting any straight answers. I audit charts for documentation and education for our Hospitalists and some of my co-workers are sending charts back to the doctors with errors for Discharge summaries and downcoding them to Subsequent visits because they lack documentation of an Exam. So far all I have found is information stating that an Exam is not required to be documented - just a statement of the patient's health status at discharge is needed. My supervisor is supposed to be sending me information saying that the exam is required to be documented, but I have not seen it yet. Does anyone have any solid information on what needs to be documented in a Discharge Summary?
All information would be greatly appreciated!![Smile :) :)](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
Thanks,
All information would be greatly appreciated!
Thanks,