Discharge Summary

Does anyone have a good reference on what is required to be included in the Discharge Summary?  We are in the process of changing our discharge documentation process and attempting to combine routines that will allow the physician to document information only once in the record.  This is in an effort to create discharge instructions and discharge summary electronically in one task, without duplicating efforts.
This is what our coding team came up with from AHIMA, but other than this, we haven't come up with anything solid except for suggestions for best practice.

Discharge Summary

The discharge summary is viewed as the synopsis of all events during the patient's stay. It is important that the discharge summary is just that--a summary of events already chronicled in the patient's record. Events, diagnoses, and assessments should not be recorded for the first time in the patient's discharge summary. At least, clinical evidence of every condition documented in the discharge summary should be found somewhere in the patient's history and physical, progress notes, orders and/or operating room reports.

Thank you for any help



  • From what I understand the DS is governed by JHACO and is utilized to assist the outpatient provider during f/u.
  • We don't employ JHCO, we use HFAP and they actually have different requirements.
  • Your HIM department ‘should’ require the Discharge Summary contain the required Information Management elements as per ‘your accrediting ‘ entity - such as JCAHO or HFAP.  I have only worked at sites accredited by JCHAO, and it makes statements to the effect that ‘all major conditions present and treated’ should be referenced in a summary.   I am not familiar at all with HFAP - but, I’d think it also cites the required summary elements.

    Good luck - in my experience as someone that has been a lead on 3 JHACO surveys, and as a coding manager, consultant, and now a CDI professional, I have no hesitation stating most summaries I have reviewed are written very, very, poorly, and if one relied upon a summary for coding, then we’d almost never:  
    1.  Code the PDX properly.
    2.  Code All risk factors properly.
     3. Report  chronic conditions that are ‘stable’, but still require reporting, such as DM, COPD, HTN, as a few examples.

    There is currently NO official requirement found in any of the governing entities overseeing the function of proper coding that state we ‘must’ restrict our coding ‘only’ to what is in the summary.  Many 3rd parties make this claim, and it is false.

    Paul Evans, RHIA, CCDS
  • Thanks Paul,

    Agree with everything you said.  I wanted to make sure there wasn't anything else out there aside from the HFAP requirements, but it doesn't look like there is. 

    Thank you!

  • Happy to offer an opinion on this complex issue.  I’d agree ‘Best Practice’ would be that the summary contain ALL relevant diagnoses for each encounter - however, obviously color me skeptical this is consistently the case.  I do take issue with those that challenge the coding of a condition clearly documented within the body of the record with ‘clinical support’, but are not in the Summary.  Unfortunately, this is sometimes a ploy used to unjustly deny claims IMO.

    P. Evans
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