The Joint Commission has established standards (Standard IM.6.10, EP 7) outlining the components that each hospital discharge summary should contain:
- Reason for hospitalization: Chief complaint, including a description of the initial diagnostic evaluation
- Significant findings: Admission and discharge diagnoses (as well as those conditions resolved during hospitalization)
- All diagnoses documented in coding based diagnostic language
- List all possible and probable diagnoses in the discharge summary
- Procedures and treatment provided: Consults, procedure findings, surgical findings, test results, etc.
- Patient’s discharge condition: How the patient is doing at time of discharge
- Patient and family instructions: Includes discharge medications, follow up needed, list of all medications changed and/or discontinued, dietary needs, follow up tests or procedures
- Attending physician’s signature and date of service
The Discharge Summary should not introduce new information, nor should it conflict with previous documentation substantiated in the record.
*Remember that most records are coded and billed within 24 hours of the patient’s discharge*
Studies have demonstrated a trend toward a decreased risk of readmission when the discharge summary arrives before the outpatient follow-up visit takes place. The study, by van Walraven and colleagues (J Gen Intern Med. 2002; 17:186-192), found a 0.74 relative risk of decreased rehospitalization for these patients.
Download the complete tip, Discharge Summaries.