Discharge Summaries

Download this tip

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.