Discharge Summaries

cstukenbergcstukenberg
in CDI Talk Archive
Hi. Does anyone have a reference that details the specificity of what is needed in the discharge summary when it comes to coding the final record? An example is if the physician documents acute systolic heart failure in a few of the progress notes but only documents CHF in the discharge summary, Does the discharge summary have to have the type of CHF in the discharge summary or can the prior part of the record be enough to support the acute systolic CHF?
If anyone has a reference to support their answer it would be appreciated.
Thanks
Sign In or Register to comment.