Discharge Summaries for Observation

Hello all,

If an observation patient stays over 48 hours (we have one that stayed 72 hours), do you assign a discharge summary? I know this is an inpatient requirement but if a patient stays that long, it seems like something more than a discharge diagnosis is needed.

Thanks for your help.


  • edited May 2016
    Our R&R specify documentation requirements based on length of stay, regardless of IP vs OBS.
    48 hrs or less, we will accept a detailed final progress note containing all the required elements per CMS.
    more than 48 hours, we require a DS.
  • edited May 2016
    We do not require a discharge summary for observation accounts of any
    length of stay.

    Sheila Schultz

    Director of Medical Records

    Wheeling Hospital

    One Medical Park

    Wheeling WV 26003


  • edited May 2016
    We do not require a discharge summary for observation for any length of stay, but our hospitalists dictate a DS for them.

    DeLinda Bennett
    Director Health Information Management
    J. C. Blair Memorial Hospital
    1225 Warm Springs Avenue
    Huntingdon, PA 16652
  • edited May 2016
    Thank you all for your help with this.
  • edited May 2016
    We do not require it at this point but have put it in revised draft rules & regs. CMS Conditions of Participation require a "summary" for all stays , not just inpatients.

  • edited May 2016
    Same for Driscoll Children's Hospital
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