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10 facts about a discharge summary

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When a patient is discharged from a hospital, a discharge summary or clinical résumé to document the care provided to the patient during his or her inpatient hospitalisation is prepared by any qualified individual such as the patient’s physician, a house medical officer, or a clerk.

This discharge summary placed in the patient’s record provides information for continuity of care and facilitates a medical staff committee review and it can also be used to respond to requests from authorised individuals or agencies (e.g., a copy of the discharge summary will suffice instead of the entire patient record).

10 contents of a discharge summary documents the patient’s hospitalisation which includes:

  1. the reason(s) for admission
  2. significant physical and other findings(e.g. brief clinical statement of chief complaint and history of present illness)
  3. significant diagnoses and co-morbidities(example, Principal diagnosis: Cellulitis and gangrene, left foot and lower leg. Comorbidities: Diabetes mellitus, insulin dependent, controlled. Staphylococcus aureus coagulase positive septicemia. Urinary retention)
  4. diagnostic and therapeutic procedures(example, Principal procedure: Amputation, left leg, above knee. Secondary procedures: Suprapubic cystostomy with permanent suprapubic drainage)
  5. significant medication and treatments(medical and surgical) and patient’s response to treatment, including any complications and consultations
  6. patient’s condition/status at discharge
  7. discharge medications and all medications to be taken at home
  8. follow-up instructions(patient education when applicable), to patient and/or family (relative to physical activity, medication, diet, and follow-up care)  including instructions for self-care, and that the patient/responsible party demonstrated an understanding of the self-care regimen
  9. unless contrary to policy, laws, or culture, patients are given a copy
  10. a copy is provided to the practitioner responsible for patient’s continuing or follow-up care

I am sure your hospital policy and procedures defines when a discharge summary must be completed, and that it must be placed in the record.

Such a policy and procedures are affirmed by the Joint Commission International(JCI) standard ACC.3.2 which states that “the clinical records of inpatients contain a copy of the discharge summary” and requires that a discharge summary must be prepared at discharge by a qualified individual, it contains follow-up instructions, that a copy  is placed in the patient record, the patient is given a copy of the discharge summary unless not allowed by hospital policy, laws, or culture, and a copy of the discharge summary is provided to the practitioner responsible for the patient’s continuing or follow-up care.

JCI Standard ACC.3.2 is expanded by JCI Standard ACC.3.2.1 which further qualifies the contents of a complete discharge summary.

The above 10 facts listed above covers all that is required by the 6 MEs of ACC.3.2 and the 6 MEs of ACC.3.2.1, when the discharge summary placed in a medical record is reviewed during a Medical Records Review.

Note : In Malaysia, the patient’s physician or a senior medical officer but NEVER a clerk, is responsible to prepare the discharge summary.

5 transfer process entries that must be entered in a medical record

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A patient might require a hospital transfer for a number of reasons. The patient or the family might want a second opinion, the current hospital cannot address the needs of the patient, or the new hospital offers more advanced care among other reasons.

When a patient is transferred to another hospital or health care organisation, the transfer process is documented in the patient’s medical record.

A HIM/MR professional needs to be aware of five transfer process entries which must be included in a medical record when a patient is transferred to another hospital or health care organisation.

These 5 transfer process entries as documented in the medical record will state and/or contain :

  1. the name of the hospital or health care organisation and name of the individual agreeing to receive the patient
  2. any documentation or other notes as required by the policy of the transferring hospital for example, a signature of the receiving nurse or physician, name of the individual who monitored the patient during transport
  3. the reason(s) for transfer
  4. any special conditions related to transfer such as when space at the receiving hospital or health care organisation is available, or the patient’s status
  5. any change in patient condition or status during transfer for example, the patient dies or requires resuscitation

If your hospital is in the process of becoming a Joint Commission International(JCI) accredited hospital, you need to know that the JCI Standard ACC.4.4 requires that a transfer process from one hospital(health care organisation) includes the above mentioned 5 transfer process entries in the patient’s medical record.

However, do take note that the JCI Medical Records Review Tool does not list documentation required by policy requirements of the transferring hospital, as one of its measurable elements.

5 Common Coding Errors and How to Prevent Them

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I know for a fact that most of you who code using ICD-10 in public and private hospitals in Malaysia, are conscientious, dedicated, hard-working, and detail-oriented as medical records professionals.

I am sure when erroneous mordbitidy and mortality statistical reports shows discrepancies and weird facts, and when errors in your ICD-10 coding work are discovered, most of you are extremely upset with yourselves, and you would sensibly work even harder to improve your coding skills.

Although as humans we inevitably make occasional mistakes.

What is lacking I think is, an auditing process in Malaysia, where an analysis of common errors found in auditing inpatient records can be done.

I diged into my journal and notes of coding experiences, and I like to post and share this tuesday morning, 22 May 2012 what I think are the 5 most reasons as outlined below, why coding errors are made. This post addresses some of the common coding errors and suggests some ways to prevent them, as I see it. An insight (knowing) where the “traps” lie dormant, should help you to avoid them.

1. Rush to get the work done:
When you choose productivity or rushing over your job of coding inpatient records as a priority over quality, this can cause you  to rush through a medical record without thoroughly reading all available documentation. Additionally, the distractions and disruptions that occur in you workplace environment may result in errors.

2. Assigning diagnosis codes from memorising:
I know the many experienced amongst you who cannot help but memorise many code assignments after using them repeatedly. Sometimes, however, our memories fail and the direct entry of memorised codes may lead to error.

3. Incomplete or inadequate documentation:
When documentation is incomplete or conflicting, it is difficult for you to code completely and accurately. Since we code before discharge summaries or other dictated reports are available (correct me if I am wrong), final conclusions/diagnoses may differ from those determined by the you in reviewing History & Physical Examination reports and progress notes alone.

4. Incorrect principal diagnosis selection:
Errors in selecting the principal diagnosis may be the result of a lack of knowledge of basic coding principles and terminology. The quality of your initial training program and/or “on-the-job experience” is fundamental to building your  expertise, as is your ability to stay abreast of current coding guidelines. Misunderstanding or misinterpreting a coding guideline may also occur by failing to read inclusion and exclusion terms, and coding references during the coding process. Common examples of incorrect principal diagnosis selection including :

  • Coding a condition when a complication code should have been selected instead
  • Coding a symptom or sign rather than the definitive diagnosis.
  • Assuming a diagnosis without definitive documentation of a condition
  • Coding from a discharge summary alone.
  • Incorrectly applying the coding guidelines for principal diagnosis, especially in a situation where the coder selects the diagnoses when two or more diagnoses equally meet the definition of principal diagnosis.

5. Incorrect or missing secondary diagnoses:
Secondary diagnoses are frequently coded when they do not meet the criteria for reporting secondary diagnoses. Some of the “traps” in coding secondary diagnoses are found in the doctor’s documentation.

Examples include:  (1) Using the term “history of” for conditions that are currently under treatment, as well as for those that have been resolved prior to admission; (2) Misusing the term “coagulopathy.” It is often documented when a patient on anticoagulant therapy has an expected prolonged prothrombin time, rather than a true coagulopathy.   Secondary diagnoses may be missed by when you attempt to code from a discharge summary alone without reviewing all documentation.

RECOMMENDATIONS :

  1. Focus on quality, not just productivity. The quality of coded data is more critical This fact justifies taking the time to focus on coding accuracy and reading medical record documentation thoroughly. Try to eliminate as much of the daily distractions and disruptions in the workplace as possible.
  2. Query conflicting and incomplete documentation. When a record has been coded without a final discharge summary, a process should be developed for reviewing them when it is complete.
  3. Apply critical thinking skills when reviewing documentation and code assignments.
  4. Always refer to the ICD-10 Instruction Manual to understand the official WHO coding guidelines for principal diagnosis. When multiple conditions may be present or suspected on admission, it is especially challenging to determine if the guideline for two or more diagnoses meeting the definition of principal diagnosis may be applied.
  5. Review all questionable code assignments with your senior or another person who also codes using ICD-10; sometimes a discussion with another ICD-10 user  is enough to clarify your questions.
  6. If you need to discuss with the doctor making the final diagnosis, query as necessary; be clear and concise and avoid “leading” the doctor to alter a diagnosis (this is sensitive material, however I think the how-to is covered in the ICD-10 Instruction Manual, you can check).

  7. Exercise care when coding secondary diagnoses from the History & Physical Examination. Remember that the definition of “other diagnoses” for reporting purposes is conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. A condition that meets only one element of this definition may be coded; conditions that do not meet this definition should not be coded.

Pals, I am no expert in ICD-10, but I think you out there as responsible medical records staff, must realise the importance of accuracy in coding that cannot be underestimated. I am sure we do not wish our statistical reports on morbidity and mortality to be rediculed. Perhaps it is the time to assess your coding skills and use all resources available to improve them to ensure coded data of the highest quality.

10 Ways to Lose Your Medical Records

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Medical information in medical records can fall into the wrong hands, things can go wrong. Here are 10 scenarios where medical records could be stolen — some you might have expected or encountered, while others could be surprising.

Laptops Left in the Car
“One of the least secure places for your medical data is on a medical staffer’s laptop, especially if it’s left in a car.”

My comments :Medical staff don’t carry medical data in their laptops here in Malaysia, but a doctor could be carrying the medical report for a dignitary or a political figure in his/her laptop left in a car, and political adversaries could target such sensitive information.

Computer Viruses
“Hackers are mainly interested in stealing banking passwords and similar data, but when they infect medical-office computers going after that information, health files often fall into their hands. This is another common way health data are compromised.”

My comments : Our local hackers seem busy defacing Government owned websites rather than infecting medical records office computers going after medical information which do not seem lucrative enough.

But we know of the real threat of computer viruses.in our hospitals, and so more often hear sad stories of lost data from hard days’ work, due to lack of organised backups.

A Surprising Lesson
“A teacher at Naugatuck Valley Community College in Connecticut was discovered to be using patient X-rays from Saint Mary’s Hospital to teach a class on radiology technology. The X-rays contained patient names and physician notes. The hospital apologized.”

My comments : The next time the Radiology Colleges here ask to borrow x-rays for teaching, be wary and do have in place policies, a penny for your thought.

iCRf2UBeH_0gOffice Employees
“The staffs at hospitals and the doctor’s office aren’t always looking out for your best interests. Employees have been caught using patient information to file bogus medical claims and tax returns, create “ghost” employees, sell to gang members and pry into the lives of celebrities.”

My comments : How true, here too!

Take That E-mail Back
“Well-intentioned medical workers have also been known to lose patients’ electronic files by sending them in e-mails to the wrong people.”

My comments : A possible scenario in our paper-less hospitals, if there is an option in the software to attach EMRs.

Available on the Web
“Medical providers have inadvertently posted private health data to their public websites. A recent example was Phoenix Cardiac Surgery in Arizona, which was accused of posting surgical appointments on a publicly accessible Internet calendar. The company paid $100,000 in a settlement with the U.S. Department of Health and Human Services and agreed to change its policies concerning patient data.

In another incident, a contractor for Stanford Hospital sent a spreadsheet containing information on 20,0000 emergency room patients to a job candidate as part of a skills test. The job seeker then posted the data on a website, asking for help with the test, according to the New York Times. The hospital severed its relationship with the contractor.”

My comments : For example, if your private clinics group/hospital uses the ever so popular free Google calendar (an Internet calendar), they can be easily embedded into the clinics group/hospital website, and whola, the whole world wide web (W4) audience can view your patients’ details.

Never give out unpublished official data in any form, especially the many spreadsheets we prepare in our statistical reports.

Dumpster Diving
“Much of the health-care industry still uses paper to record sensitive information about patients. Another common way breaches occur is for those documents to be thrown in the trash without shredding. Patient documents, including X-rays, have been found blowing across fields and overflowing from garbage and recycling bins.”

My comments : A common phenomenon in our public hospitals, but surely also in private healthcare institutions.

Cleaning Crews
“Janitorial workers have mistakenly thrown away computers that contained sensitive information. One example occurred last year in Pennsylvania when a cleaning crew for Lebanon Internal Medicine Associates improperly disposed of a computer server that had more than a decade’s worth of patient information. The company said the files were likely inaccessible because of damage to the machine from being submerged in floodwater.”

My comments : Luckily our janitors don’t cart away computers, but surely they could mistakenly pull documents off your desk into their waste-bags, especially if you leave your records and documents/reports so carelessly clustering your workplace environment.

Precious-Metals Miners
“Medical images have value beyond being diagnostic aids. Thousands of X-rays were stolen last year from hospitals in Maryland, Pennsylvania, Massachusetts and other states for their silver content instead of identity-theft purposes.”

My comments : OH, just another familiar scenario here, but our thieves are not that adventurous yet.

Natural Disasters
“Medical files have been found flying around city streets after fires, floods and other natural disasters have scattered the records. These types of breaches are a reminder that while electronic health records are vulnerable to computer hackers, paper records can be vulnerable to Mother Nature.”

My comments : Fortunately,  we are sure lucky and blessed that Mother Nature has been extremely kind that we don’t get in Malaysia hurricane Katrina style disasters or Aceh style tsunamis sweeping away our hospitals and the records downstream and clinging onto rooftops.

Abridged, from an original article by Jordan Robertson – May 16, 2012, bloomberg.com, with comments by R. Vijayan