Wiki Discharge Summaries

[AmandaW]

Can anyone help me with what a discharge summary HAS to have? All of my research has told me what SHOULD be in there, or what the pt's PCP and other Dr's would LIKE in there-but what absolutely has to be in there at the minimum?

 

[bertll]

I have wondered the same thing. In the CPT book it says "as appropriate" there should be a discharge exam and hospital course. Obviously the time spent needs to be there. What does "as appropriate" mean?

 

[mhstrauss]

Here is a link to an article about the requirements for discharge summaries; it includes a checklist for what should be included. Google "documentation requirements for discharge summaries" and there's probably quite a bit more info so that you can get it in writing for your providers.


http://www.acphospitalist.org/archives/2009/03/discharge.htm

 

[AmandaW]

Thank you Meagan. I did actually see that link while I was researching this topic. It is a very good link for like I was saying above, i.e., what would be good and beneficial to be documented, but still can't find what exactly at minimum HAS to be in there. Like we have with the regular E/M guidelines...(need 2 out of 3, detailed history, expanded exam, etc.) Haven't seen anything like that for D/C summaries. Maybe you don't have to really have anything other than the date of d/c and diagnosis and for the Dr. to say he/she's discharging the patient. (???)

 

[mhstrauss]

Here's 1 more...this 1 states what is "mandated", so i would think this would be the minimum requirements...



http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Kind_31.pdf

 

[AmandaW]

Awesome! Thank you! I'll have to look more up about 'Joint Commission' and if they go by Medicare or what. But this is great!