Discharge Summary is the most Important document that hospitalists prepare.
It is the first document hospital coders review when they start coding any given hospitalization. The Discharge Summary is considered the final diagnostic statement for the entire hospitalization. So we should include a complete list of every diagnosis or medical issue that impacted your patient’s care during their hospitalization.
If not documented properly, coders will send us queries for clarification. Sometimes, they send queries even before the patient is discharged.
Most Common Medicine Queries are
• Heart Failure – systolic, diastolic or both and whether it is acute, chronic or acute on chronic
• Pneumonia (Organism)-Type of pneumonia e.g. Aspiration pneumonia or Gram negative pneumonia
• Anemia-Type (Blood Loss, Acute/Chronic)
• Sepsis – source of the sepsis and the causative organism
• Atrial Fibrillation– Persistent, Paroxysmal
• Respiratory failure– 1. Acuity- a. Acute, b. Chronic, c. Acute on chronic, d. Unable to determine. 2. Type- a. With hypercapnia, b. With hypoxia, c. With hypercapnia and hypoxia. d. Unable to determine
• Present of admission-Always mention whether they were present on admission [POA].
Present on Admission: Anything captured in PMH or A/P sections of H&P is considered POA
• Principal Diagnosis-Discharge summary should mention what the primary diagnosis is for the patient’s admission.
• CKD= Stage of CKD, Etiology of the CKD 1. Diabetes mellitus, 2. Hypertension.
Always Document
1. Laterality: left vs right for bones, organs, blood vessels, strokes, injuries, etc.
2. Status of disease: Acute vs. Chronic vs. Acute on Chronic
3. Anatomy: Specific bone in hand or foot, lobe of lung, exact blood vessel
4. Location of Insult: AMI of anterior wall, Left MCA stroke, etc.
5. Medical Linkage:
A. Acute Blood Loss Anemia due to GI bleed, B. UTI due to indwelling Foley catheter, C. CKD stage 3 due to DM, D. Cirrhosis due to Hep C, E. Sepsis due to Pneumonia…etc.
Associated &/or related conditions: DM with hyperglycemia and retinopathy, Cirrhosis with ascites and esophageal varices, etc.
Document Glasgow Coma Scale for encephalopathic or comatose patients.
Mention if Alcohol/Specific Drug/Nicotine dependence with or without withdrawal.
