Time to take action
With the help of our hospital quality improvement (QI) committees, we can take action to restore the integrity of the discharge summary. Consider the following:
- Advocate timely completion of the discharge summary and overall chart, preferably within a week of the patient’s discharge. The Medicare Conditions of Participation require that the entire medical record be completed (i.e., signed, sealed, and delivered) within 30 days of inpatient discharge; some states, such as California, have stricter deadlines. Summaries must be performed within seven to 10 days if they are to be typed and signed prior to the 30-day deadline. Even with these generous deadlines, good patient care requires that we do our summaries as soon as possible.
- Insist that discharge summaries meet quality standards. Have the QI committee audit physician discharge summaries for at-risk conditions, such as pneumonia, myocardial infarction, and heart failure. Involve the coding manager or clinical documentation specialist to learn how the terminology used affects resource intensity or risk of mortality determinations. Follow up with a corrective action plan when deficiencies are found.
Thank you again for the efforts you take to ensure data quality. Please let me know of other topics you would like me to address in this column.
Editor’s note: This is the third part in a three-part series. To read the previous two sections, click here and here. Kennedy is the president of CDIMD-Physician Champions in Nashville, Tennessee. This article was originally published in the Revenue Cycle Advisor. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board.