When records are received in the HIM department after discharge or conclusion of the visit what is the first thing that should be done?

A discharge summary plays a crucial role in keeping patients safe after leaving a hospital. As an Advances in Patient Safety report notes, "Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care. High-quality discharge summaries are generally thought to be essential for promoting patient safety during transitions between care settings, particularly during the initial post-hospital period."

While the development of electronic solutions has helped improve communication about patient information as they move from one health care setting to the next, use of these resources does not negate the importance of and a hospital's responsibility for completing a discharge summary. As a Joint Commission Journal on Quality and Patient Safety report notes, "… incomplete discharge summaries remain a common problem that may contribute to poor post-hospital outcomes." 

6 Components of a Hospital Discharge Summary

As a For the Record report points out, The Joint Commission mandates all discharge summaries must contain six high-level components, which are also noted as requirements in the National Quality Forum's Safe Practices for Better Healthcare.

The Advances in Patient Safety report referenced earlier shares these components and includes a consensus definition arrived at by two physicians and one geriatric nurse practitioner. for each. These are summarized as follows:

1. Reason for hospitalization:

• description of the patient's primary presenting condition; and/or
• description of a patient's initial presentation to the hospital admission, including description of the initial diagnostic evaluation.

2. Significant findings:

Primary diagnoses.

3. Procedures and treatment provided:

• description of the events occurring to a patient during the hospital stay; and/or
• description of surgical, medical, other specialty, or allied health consults a patient experienced as an inpatient (or a note of "no consults"); and/or
• description of surgical, invasive, noninvasive, diagnostic, or technical procedures a patient experienced as an inpatient (or note of "no procedures").

4. Patient's discharge condition:

Documentation that gives a sense for how the patient is doing at discharge or the patient's health status on discharge.

5. Patient and family instructions (as appropriate):

• discharge medications; and/or
• activity orders; and/or
• therapy orders; and/or
• dietary instructions; and/or
• plans for medical follow-up.

6. Attending physician's signature:

A signature (electronic or physical) of the attending physician on the discharge summary.

For extensive information regarding these six mandatory discharge summary elements, click here.

Additional Hospital Discharge Summary Recommendations

While these six components can serve as a strong foundation for what your hospital should address in its discharge summary, consider whether it would be worthwhile to include other components that can help improve patient safety.

One set of standards you may want to consider came out of the Transitions of Care Consensus Conference (TOCCC), a meeting convened by the American College of Physicians, the Society of General Internal Medicine, and the Society of Hospital Medicine (SHM), with representation from the emergency medicine community.

As a Journal of General Internal Medicine article notes, TOCCC proposed a minimal set of data elements that should be included in the transition record (which overlap with the components outlined above). TOCCC also recommended additional elements for an "ideal transition record."

These were identified as follows:

• emergency plan and contact number and person;
• treatment and diagnostic plan;
• prognosis and goals of care;
• advance directives, power of attorney, consent;
• planned interventions, durable medical equipment, wound care, etc.;
• assessment of caregiver status; and
• patients and/or their family/caregivers receive, understand, and be encouraged to participate in the development of their transition record, taking into consideration the patient's health literacy and insurance status, and be culturally sensitive.

Access to Post-Discharge Summaries

It should be mentioned that while comprehensive, accurate discharge summaries are essential to follow-up care, their availability to primary care providers is just as crucial.

In a study published in The Journal of the American Board of Family Medicine, providers surveyed indicated that they only “…had a [post-discharge] summary available 0% to 40% of the time, 41.4% noted availability 41% to 80% of the time and 31.1% >80% of the time.”

The study concluded that significant opportunities exist to improve the timeliness and availability of PDS through a combination of process redesign and electronic medical record utilization.

To read the entire study, click here.

Discharge Summary Resources

Looking to create or update a hospital discharge summary? There's no need to reinvent the wheel. You can emulate hospital discharge summaries used by other organizations. Here are a few resources you may find helpful:

• Discharge summary template from The University of Tennessee Health Science Center (click here)
• Sample discharge summary from the Creighton School of Medicine (click here)
• Discharge summary checklist from HSHS Sacred Heart Hospital (click here)
• Discharge summary outline from J.W. Ruby Memorial Hospital (click here)
• Hospital discharge summary form from Tufts Health Plan (click here)

Which of the following is the correct order when filing patient records?

Why is it important for patient records to be complete and specific?

Which of the following is the goal of quantitative analysis performed by him professionals?

What is the time period that all entries in the medical record must be signed?