Discharge Summaries

Do you have a specific policy that addresses who completes a discharge summary for your facility and do you allow physician groups to decide who does the discharge summary?

For example: There are some offices where one group practice will say whoever admits the patient and does the H&P will complete the discharge summary and then there are other practices that say whoever discharges the patient will do the discharge summary.

Do you have a policy that states across the board for all physicians who will do the discharge summary or is your practice similar to ours?
If you have a policy, would you please share it with me?

Thank you.


Thank you.

Liz Watson, MA,RN,RHIT,CPHQ
Director, Medical Information Dept
West Georgia Health System
1514 Vernon Rd
LaGrange, GA 30240
Phone: 706.845.3100
Fax: 706.845.0034
email: WatsonL@wghs.org
«1

Comments

  • edited May 2016
    Our standard is whomever discharges the patient, however we permit
    physician groups to communicate to us a different standard if there is
    group consensus (e.g. surgeon to dictate regardless of discharging
    partner). There aren't many variations to our standard thus it's
    reasonable for us to accommodate their request.

    Andrea B. Thomas, MBA, RHIA
    Director, Clinical Information Management
    Lancaster General Hospital
    abthomas@LancasterGeneral.org
    (717) 544-4060
  • edited May 2016
    Our standard is written in the medical staff rules and regs which says that
    "Attending Physician: The physician responsible for the majority of the
    care of the patient. the admitting physician unless otherwise specified in
    physician orders. This physician would be writing the majority of the
    orders, requesting consultations and arranging coverage. Does not become
    attending physician without a specific order assuming primary care of the
    patients.

    Establishes discharge plan on admission
    Responsible for the discharge summary
    If not the patient's primary care provider - ensures that discharge
    summary copy is sent for office medical record"


    There are times when groups want to differentiate from this standard and say
    whoever discharges the patient is responsible. But at times, we get the
    runaround and it always defaults to the "Attending Physician"....if we have
    to, we send a letter with the verbage above, and signed by the HIM Chair.
  • edited May 2016
    The Medical Staff Regulations states that the attending physician is
    responsible for completion of record including DS, but not that he has
    to dictate it. The physician groups decide here.

    Brenda W. Tuck, RHIT, CCS
    Director HIM/Privacy Officer
    Granville Medical Center
    919-690-3000 Ext 4423
    BTuck@granvillemedical.com
  • edited May 2016
    We let different groups decide, as there aren't many. The family practice and internists are sometimes a problem. We've encouraged them to write in the last order "Dr. ____ to do discharge summary" if it isn't going to be the one discharging.

    Shari Grace, RHIA
    Director, Health Information Management & Privacy Officer
    Marshalltown Medical & Surgical Center
  • edited May 2016
    Shari, good idea. Thank you. Liz
  • edited May 2016
    We practice the same protocol as Andrea.


    Norma Knipp
    Manager, Health Information
    Privacy Officer
    North Kansas City Hospital
    816-691-1590 phone
    816-346-7311 fax
    norma.knipp@nkch.org
  • edited May 2016
    We don't require it within the dictated discharge summary. We do
    document it on other interdisciplinary discharge forms.

    Andrea B. Thomas, MBA, RHIA
    Director, Clinical Information Management
    Lancaster General Hospital
    abthomas@LancasterGeneral.org
    (717) 544-4060
  • edited May 2016
    Ditto.


    Norma Knipp
    Manager, Health Information Department
    Privacy Officer
    North Kansas City Hospital
    North Kansas City, MO 64116
    norma.knipp@nkhc.org
    816-691-1590
  • edited May 2016
    We have that info on the Patient Instruction Sheet.
  • edited May 2016
    Does anybody remember where the instructions for discharge came from regarding diet and activity, medications, and followup care? It's not so stated in the JCAHO manual as far back as 2003.
  • edited May 2016
    You'd have to be older than that to remember, 10 years ago or more! Unfortunately, I am old enough to remember when the specifics for a discharge summary were part of the JCAHO standards. :-)

    Barbara Perrett, RHIA, CCS, CHP, CHC
    Director of Health Information Mgmnt/Privacy Officer
    El Dorado Hospital Tucson, Arizona
    520-751-8250 FAX 520-721-5157
  • edited May 2016
    Jo Ellen:

    We allow physician's nursing staff or PA's to dictate discharge summaries
    on behalf of the physician and do not have the requirement that they had to
    particiapte in the care of the patient to do so. However, we currently do
    not have our own hospital staff dictate discharge summaries for providers.

    Marcia Matthias
    Corporate Director, HIM
    Southern Illinois Healthcare
  • edited May 2016
    10 days

    Marcia Matthias, MJ, RHIA, CHPC
    Corporate Director Health Information
    Privacy Officer
    Southern Illinois Healthcare
    Carbondale, IL
  • edited May 2016
    New York State: 30 days from discharge

    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
    30 days from discharge.

    DeLinda Bennett
    Director Health Information Management
    J. C. Blair Memorial Hospital
    1225 Warm Springs Avenue
    Huntingdon, PA 16652
    (814) 643-8812
    (814) 643-7067 (fax)
    dbennett@jcblair.org
  • edited May 2016
    30 days, but with EHR's and meaningful use they are wanting us to change to 7 days
  • edited May 2016
    30 days.

    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
    Ours is 14 days from date of discharge.


    Catherine S. Kadry, RHIT, CCS, CHA
    Director, Health Information Management
    Pioneers Memorial Healthcare District
    207 W. Legion Road
    Brawley, CA 92227
    Phone (760) 351-3148 Fax (760) 351-3154
  • edited May 2016
    7 days, most are done the day of discharge.

    Thanks,
    Shari Grace
    MMSC
  • edited May 2016
    14 days


    Glenda Stottlemyre, RHIT
    HI Director/QA/Compliance
    Hamilton Memorial Hospital District
    Telephone 618-643-5562
    Fax 618-643-7047
  • 30 days


    Emily West, RHIA
    Director, Health Information Services
    Doylestown Hospital
    PH:
  • edited May 2016
    30 days

    Suzanne LeMaire, RHIT
    HIMS Leader
    Scheurer Hospital
    170 North Caseville Road
    Pigeon, MI 48755-9781
    phone: 989.453-5205
    fax: 989-453-4455
    email: lemaires@scheurer.org
  • 30 days

    _________________________________________________________
    Terri R. McDaniel, Director HIM, Privacy Officer and Interim Compliance Officer
  • edited May 2016
    30 days-
    Pam
    Director/HIM
  • 10 days after discharge.
  • edited May 2016
    In our facility it is in medical staff regulations or by-laws, not sure which one and states that patient's with a stay of less than 48 hours do not require a discharge summary if the stay is uncomplicated and of a minor nature.....well, now the OB doctors are discharging cesarean sections within two days and do not want to do a discharge summary. I consider a CS a major surgery but they are requesting me to take this requirement to OB meeting for staff approval (guess who will win?). I also looked in COP's and JCAHO and could not find any regs stating that. We are a DNV hospital also so please let me know how you fair with this. It might give me some ammunition to use to correct our situation also. DNV regs are silent on the matter also as far as I could find.



    Catherine S. Kadry, RHIT, CCS, CHA
    Director, Health Information Management
    Pioneers Memorial Healthcare District
    207 W. Legion Road
    Brawley, CA 92227
    Phone (760) 351-3148 Fax (760) 351-3154
  • edited May 2016
    Did you check into the regulations of the Centers for Medicare and
    Medicaid?



    Suzanne LeMaire, RHIT

    HIMS Leader

    Scheurer Hospital

    170 North Caseville Road

    Pigeon, MI 48755-9781

    phone: 989.453-5205

    fax: 989-453-4455

    email: lemaires@scheurer.org
  • Copied out of COP for you: (See last in yellow):


    A-0468

    (Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)

    [All records must document the following, as appropriate:]

  • edited May 2016
    Yes. CRF 482.24( c)Standard: Content of Record (2) All records must document the following, as appropriate: (vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care. (iii) says that "Final diagnosis with completion of medical records within 30 days following discharge".
  • edited May 2016
    Thank you. The 48 hours is in our Rules and Regulations also but it was based on something I can't find now. I thought it was Title 22 maybe it was a JCAHO standard which we wouldn't be following now since we are DNV. I'll go over them again, especially the DNV as I am not well versed in it yet.
Sign In to comment.