discharge instruction given to patients

We are debating if an exact copy of the discharge instructions that is
given to a patient needs to be in the medical record. The nurse/physician
documents in the record for example, "back pain" instructions given. IT
is stating that they can always revert back to the actual version of the
discharge instruction that was given at the time. Would appreciate
hearing what are others are doing - keeping an exact copy in the medical
record or documenting the type of instructions provided.


Marcia Matthias, MJ, RHIA, CHPC
Corporate Director Health Information
Privacy Officer
Southern Illinois Healthcare
Carbondale, IL


  • edited May 2016
    Sometimes our discharge summaries are modified so we image a copy in of all discharge instructions. It is a lot of extra paperwork if they have several sets. At a minimum, I think the patient signature page that they received a copy of them should be in the chart.
  • edited May 2016
    There is an electronic copy in the electronic portion of the record. The page the patient signs comes with the paper chart.

    Sheila Schultz
    Director of HIM
    Wheeling Hospital
    One Medical Park
    Wheeling WV 26003
    Fax 304-243-8599
  • edited May 2016
    Yes- we keep a signed copy of the instructions with the legal record.

    Maryellen McGowan, MS, RHIA, CPC
    Director Of Health Information Management
    & Clinical Documentation Improvement
    Winthrop University Hospital
    259 1st Street
    Mineola, New York 11501
    (P) 516-663-8901
    (F) 516-663-2729
    E- Mail: mmcgowan@winthrop.org
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