Q&A: Conflicting documentation in the discharge summary

Q: I’ve heard people say that CDI professionals should be wary of conflicting diagnoses that occur in the discharge summary as the provider’s documentation may not “conflict” with the consulting provider. Can you clarify what that means?

A: It’s a common problem: the CDI specialist reviews the medical record and doesn’t see any conflicts between the physicians. Then, when the attending physician dictates the discharge summary the language they use is not the same as the documentation throughout the patient’s record. In this situation, a query would be needed for clarification.

The classic example is when the attending physician documents the patient has “renal insufficiency” and orders a renal consult. The consulting nephrologist diagnoses the patient with “acute renal failure” and documents the diagnosis in the patient’s medical record. There is no mention of the diagnosis by the attending in the medical record until the discharge summary where they document “acute renal insufficiency” versus the “acute renal failure” that was documented by the nephrologist.

This situation creates a conflict which would require either the CDI specialist or coder to clarify because the attending physician’s documentation supersedes all other physician’s documentation in the medical record (see AHA Coding Clinic, First Quarter, 2014). As it would stand with coding, the diagnosis of “acute renal insufficiency” would be coded for this patient not the “acute renal failure” as documented by the nephrologist.

Another problem you may encounter is when the discharge summary is not dictated in a timely manner, physicians still have 30 days to submit the discharge summary. Usually organizations set their own policies regarding this timeframe.

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.