Physician tips provided periodically by SHC professionals

Before You Discharge

For planned discharges (i.e. discharges home or to another facility), federal regulations require that the facility complete a recapitulation of the patient’s stay, a final summary of the individual’s status based on the comprehensive assessment, and a post-discharge plan of care. The post-discharge plan of care serves as discharge instructions for a resident discharging home or as the transfer form for a resident discharging to another health care facility.

At a minimum, a discharge record should be completed which includes the date and time of discharge, disposition, final diagnoses and the discharge location/address.

Audits have disclosed that some discharge summaries list conditions that have been taken care of years before as the “discharge diagnosis.” According to regulations, it is imperative that the discharge diagnosis list only the conditions that were actually treated during the current visit.

EXAMPLE: The patient was treated for vomiting and diarrhea, and enteritis. The documentation for the “discharge diagnosis” listed only these conditions:

1. Prostate cancer, status post radiation therapy in 2001

2. Hip and knee replacement 2002 and 2003

These diagnoses do not qualify for “discharge diagnosis” this visit. The discharge diagnosis should have been listed as:

1. Gastroenteritis (per the documentation because it was treated)

2. Nausea and vomiting (per the documentation because it was treated)

-For further reference:

http://www.ahima.org/infocenter/guidelines/ltcs/6.1.asp#617

–From Barbara A. Rubin, M.Ed., MBA, RHIA. Interim Coding Manager HIMS, 650-725-6316, brubin@stanfordmed.org