Health Information Management

Discharge summaries: The role of HIM in transitions of care

HIM-HIPAA Insider, August 4, 2014

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Although HIM professionals do not treat or diagnose patients, their role in managing all the moving parts in a healthcare organization affects overall quality of care.

A prime example of this is HIM facilitation of discharge summaries and plans. "They are, or should be, the experts in regard to requirements," says Jean Clark, RHIA, CSHA, interim HIM manager at Cadence Health in the Chicago area.
As with most aspects of healthcare, a multidisciplinary approach works best for discharge summaries. HIM should work alongside physicians, midlevel providers, discharge planners, and scribes to ensure discharge summaries are timely and accurate, Clark says. 
Insufficient or late discharge summaries can lead to poor transitions of care, which can make the next level of care unnecessarily challenging and cause a decline in patient safety. "Patients' continuing care can be jeopardized without complete and accurate information," says Monica Pappas, RHIA, president of MPA Consulting, Inc., in Long Beach, California.
Consistently poor communication and summaries that result in a decline in safety and quality of care can tip off The Joint Commission and CMS, leading to requirements for improvement or a loss of accreditation, Clark says.
Follow the rules and regulations to ensure that discharge summaries are not lacking information that is critical to the next level of care. "It is the single document that serves as the communication tool for continuity of care," says Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer and founder of First Class Solutions, Inc., in Maryland Heights, Missouri. "While other documents can be provided, the discharge summary should capsulate the stay for the receiving healthcare provider and facilitate his or her understanding of the patient's hospitalization or outpatient encounter."
Continue reading "Discharge summaries: The role of HIM in transitions of care " on the HCPro website. Subscribers to Medical Records Briefing have free access to this article in the August issue.

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