Q&A: Can CDI professionals document in the discharge summary?

Q: Would there be any legal or ethical issue if a CDI nurse did the discharge summery for a group of physicians and then they agree and sign off on them?

A: Organizations sometimes develop policies with the right endgame in mind, without considering the compliance indications, unfortunately.

I often say patients’ problem lists would be perfect, their history and physicals, and discharge summaries would be awesome if only I were allowed to write them for the providers. Unfortunately, such a tactics stretches the limits of compliant CDI practice.

ACDIS consistently says that forms which identify specific diagnoses and require only a physician’s signature are not compliant. For example, some organizations capture malnutrition diagnoses by having the provider countersign the dietician’s assessment indicating malnutrition. It is generally viewed that such a practice is the same as a query and if we require only a signature in agreement to the dietician’s statement, it’s a leading query. We are basically asking “Does this patient have malnutrition? Yes, or no?” As we discuss in the CDI Boot Camp class, a yes/no query format cannot be used to obtain a missing diagnosis. (To read the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief, click here.)

As for discharge summaries, CMS has given the following guidance (emphasis added):

Interpretive Guidelines §482.24(c)(4)(vii) All patient medical records must contain a discharge summary. A discharge summary discusses the outcome of the hospitalization, the disposition of the patient, and provisions for follow-up care. Follow-up care provisions include any post-hospital appointments, how post-hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living. The MD/DO or other qualified practitioner with admitting privileges in accordance with state law and hospital policy, who admitted the patient is responsible for the patient during the patient’s stay in the hospital. This responsibility would include developing and entering the discharge summary.

CDI and coding professionals should never be considered part of the active medical team, and cannot be responsible for assessment, planning, or treatment of a patient—nor documentation of that treatment within the medical record. Such actions (even if not your intent), can be interpreted to mean that you added diagnoses or treatment plans to increase reimbursement or influence quality measures, etc. It’s a very slippery slope.

That said, we can certainly teach our providers how to write a better discharge summary and the information that should be included. But, the writing of the summary is their responsibility.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.