Book Excerpt: Documenting the discharge process

By Jackie Birmingham, RN, BSN, MS, CMAC

Editor’s note: For more information, see Discharge Planning Guide: Tools for Compliance, Fourth Edition, by Jackie Birmingham, RN, BSN, MS, CMAC. This excerpt originally appeared in Revenue Cycle Advisor, here.

Whether writing a note, completing a flow sheet, or entering information in an electronic record, a discharge planner is capturing data: facts related to actions, reactions, and decisions. For the purposes of this example, a discharge planner is writing the story about the planning that occurs to prepare for a patient’s transition to the next level of care.

Information entered into the medical record describes the final discharge plan for the patient. Organizations implement documentation policies to guide discharge planners regarding what the medical record must include.

The Conditions of Participation (CoPs) require documentation of the assessment or evaluation of a patient’s discharge planning needs. CDI specialists can use the following CoPs (c) Standard (c) to ensure the minimum evaluation topics are documented including

• “Admitting diagnosis or reason for registration;
• Relevant comorbidities and past medical and surgical history;
• Anticipated ongoing care needs post-discharge;
• Readmission risk;
• Relevant psychosocial history;
• Communication needs, including language barriers, diminished eyesight and hearing, and self-reported literacy of the patient, patient’s representative or caregiver/support person(s), as applicable;
• Patient’s access to non-health care services and community-based care providers; and
• Patient’s goals and treatment preferences”

The list above reflects the minimum standards. Discharge planners should use this list as a tool to audit a sample of patient charts to determine whether their hospital meets these minimum requirements. After completing an audit, compare the findings to the facility’s documentation policy to determine whether it addresses all necessary elements. Use this activity as an opportunity to identify potential quality improvement initiatives. Although this list aims to aid in assisting in patient discharge needs, CDI specialists can look to these notes to identify additional documentation improvement opportunities or for evidence supporting the need for a physician query. Additionally, CDI specialists should be aware of the wide variety of documentation required throughout the patient’s care, what each documentation requirement’s purpose may be, and the parties responsible for ensuring the accuracy of those documents.