A best-practice discharge summary

By Julie Shayne RN, CCDS, Intermountain Health Clinical Documentation Integrity Educator

The discharge summary can help tie the patient’s visit together. To ensure the risk of mortality and complexity of care rendered by the physician and facility are accurately coded and reported to internal and external sources, please consider the following points.

• The discharge summary should document all significant conditions that were evaluated, monitored, treated and responsible for increased nursing care and/or monitoring.

• Avoid conflicting with previous documentation substantiated in the record.

• The discharge summary should clarify whether conditions were 1) present on admission and have resolved, 2) are still to be ruled out or 3) were, in fact, ruled out.

• It is acceptable to document uncertain diagnoses as final conditions in the discharge summary, provided the diagnostic workup and therapeutic approach correspond most closely with the ‘suspected’ or ‘likely’ diagnosis. Examples include:

  • ‘Likely gram-negative pneumonia’ or ‘Likely aspiration pneumonia.’

  • ‘Atypical chest pain, suspected to be due to GERD.’

• Indicate when differential diagnoses are ‘confirmed’ or ‘ruled out.’

• Most records are coded and billed within 24 to 48 hours of the patient’s discharge. Having all necessary documents provides an accurate and complete record for the patient’s visit.

• Queries might be issued after discharge to clarify documentation. Please respond to the queries as soon as possible in Epic to ensure timely completion of coding and billing.

Remember, your CDI team is here to help and serve as a resource for your documentation needs to ensure an accurate clinical picture of the patient is reflected. Please email me if I can help you further.