Coding off patient discharge instruction form

ABWhiteRN

Hello,
We have a very onerous discharge process our providers have to navigate through.  They have to generate their discharge summaries and then create two additional documents (patient discharge instruction forms) for the patient to take home.  All forms are considered part of the permanent medical record.  There are times when the physician fails to put a diagnosis on the DC sum but puts it on the patient instruction form.  The question I have is this - can you code off the patient dc instruction form?  (disclaimer ... I am new to the CDI world)  Thank you!  Alison

Jamoo

good question, If this forms part of the permanent medical record then you should be able code from it. nevertheless, the provider should in future be advised to complete this important aspect of the discharge summary.

jennifer.fetz@nortonhealthcare.org

I guess you are talking about when the doctors prescribe a particular medicine at discharge and put what the medication is for on the patient home discharge instructions that are computer generated....such as, "Sodium tablets for hyponatremia" (this is just a simple example I thought of quickly) but the dx "hyponatremia" is never documented.  Our coders will not code off of the dc instructions without the diagnosis being in the chart either on the progress notes or dc summary.  They send it back to CDI to query.