Tip: Ensure 'complete' medical record documentation

April 1, 2010

by Glen Krauss, RHIA

A 2007 study in the Journal of the American Medical Association found that direct communication between hospital physicians and primary care physicians occurs infrequently, and that discharge summaries are often times unavailable at the first post-discharge visit.

In this same study researchers reviewed 55 previously published studies between 1970 and 2005 and found that when discharge summaries were available at time of discharge, they often lacked the requisite information such as diagnostic test results, treatment course, discharge medications, test results pending at discharge, patient or family counseling, and follow up plans.

In reviewing record discharge summaries as part of the MS-DRG reconciliation clinical documentation process, CDI specialists should look at the completeness of discharge summaries when compared to the patient’s course of hospitalization. For example, a discharge summary should include:

Primary and secondary diagnoses
Pertinent medical history and physical findings
Dates of hospitalization, treatment provided, and a brief summary of hospital course
Results of procedures and abnormal lab results
Recommendations by any subspecialty consultants
Information given to the patient and family
The patient’s condition or functional status at discharge
Details of follow-up arrangements
Specific follow-up needs, including appointments or procedures to be scheduled and tests pending at discharge
Name and contact information of the responsible hospital physician

Quality of clinical and other objective information contained in the discharge summary promotes a smooth transition post-discharge and has been shown to reduce the number of unnecessary, avoidable re-admissions due to a breakdown in communication with post acute care providers.

Providing education and promoting accuracy, complete and detailed discharge summaries, as well as H&Ps, is a logical extension of our CDI efforts beyond the scope of support of ICD-9-CM diagnoses and procedure coding.

Editor’s Note: This article was excerpted from “What is next for CDI?” written by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, an independent consultant located in Milton, WI, for the ACDIS Blog.

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Clinical & Coding