Outpatient surgery discharge summary

Do any facilities out there require the physician to do a discharge summary for an outpatient surgery or same day surgery?
Thank you.

Sheila Schultz
Director of HIM
Wheeling Hospital
One Medical Park
Wheeling WV 26003
304-243-3695
Fax 304-243-8599
sschultz@wheelinghospital.org

Comments

  • edited May 2016
    No just observation cases thanks
  • edited May 2016
    No summaries for this patient population.
  • edited May 2016
    We do not require one for OPS's nor for observations. We do require and H&P for OBS.

    CathySue Kadry, RHIT, CCS
    Director Health Information Mgmt
    Pioneers Memorial Hospital
    Phone - 760-351-3148
    Fax - 760-351-3154
  • edited May 2016
    Same at Minnesota. We don't require a discharge summary for outpatient surgery, but we do require one for observation patients.

    Pat Gastonguay, MBA, RHIA
    System Director, Health Information Management

    Fairview Health Services
    2450 Riverside Avenue, F108-2
    Minneapolis, MN 55454
    pgaston1@fairview.org | www.fairview.org
    Office: 612-273-4273 | Cell: 952-250-4811
    Fax: 612-273-4069

    Connect with Fairview Health Services on social media.
  • edited May 2016
    Read CMS 482.24: (c ) (4) (vii)

    It clearly states : the discharge summary requirement would include outpatient records.



    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
  • edited May 2016
    So you flag physicians to do a discharge summary for a same day surgery?
    Thank you.

    Sheila Schultz
    Director of HIM
    Wheeling Hospital
    One Medical Park
    Wheeling WV 26003
    304-243-3695
    Fax 304-243-8599
    sschultz@wheelinghospital.org
  • edited May 2016
    We have all the CMS elements either on the final progress note or the discharge instructions.
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