Interesting verbiage in a d/c summary
I just read this as part of a dictated discharge summary:
"Please note this is a summary and may contain errors or omissions. Please refer to the patient's full chart for the details."
Does this protect the chart when an auditor tries to swoop down on the d/c sum?
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
"Please note this is a summary and may contain errors or omissions. Please refer to the patient's full chart for the details."
Does this protect the chart when an auditor tries to swoop down on the d/c sum?
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Comments
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens