Did you know? The Discharge Summary is the most important document in the medical record.
- The Discharge Summary is the first document hospital coders review when they start coding any given hospitalization.
- The Discharge Summary is considered the final diagnostic statement for the entire hospitalization.
- Please include a complete list of every diagnosis or medical issue that impacted your patient’s care during their hospitalization.
- The Discharge Summary is also the first document Recovery Auditors review in their efforts to deny any given hospitalization and remove important diagnoses.
- There should be no conflicting documentation between what is contained in the Discharge Summary and what has previously been documented in the rest of the medical record.
- Please complete the Discharge Summary on the day your patient leaves the hospital.
- Note: Important medical information about your patients and additional significant diagnoses are lost to future providers as all memory naturally diminishes with time.
Download the complete tip, Discharge Summary Importance.