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Glossary

Discharge summary

The hospital's account of a stay: why the patient was admitted, what was found and done, the condition at discharge, the medications at discharge and the follow-up arranged. Hospitals must produce one for the record; whether the receiving agency has it before the start of care is another matter.

Also hospital discharge summary, discharge documentation

Two rules govern the discharge summary. The first, 42 CFR 482.24(c)(4)(vii), is about the hospital’s own record: it must contain a discharge summary with the outcome of the hospitalization, the disposition of the case and the provisions for follow-up care. The second, 42 CFR 482.43, is about what leaves the building. Since the 2019 discharge planning rule a hospital must send “necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences” to the post-acute provider at the time of discharge.

Between the two rules sits the problem every home health, PACE and caregiving agency knows. The summary is often not finalized at the moment of discharge; the physician dictates it later and it is signed days afterwards. What the discharge planner sends is what exists at the hour the patient leaves, and a summary that did not exist yet is not in the referral packet. The agency’s first visit then runs on the medication list and the face sheet, and the summary arrives, if it is asked for, by fax.

A network query changes the timing rather than the document. The summary, once signed, sits in the hospital’s system, and a query for the patient’s records returns it from there with the hospital’s name and the date on it, without anyone at the hospital having to be asked.

Where it is defined

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