News and Views for Healthcare Accreditation Professionals

Interpretive Guidelines §482.24(c)(2)(vii)
All patient medical records must contain a discharge summary. A discharge summary discusses the outcome of the hospitalization, the disposition of the patient, and provisions for follow-up care. Follow-up care provisions include any post hospital appointments, how post hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living.

The MD/DO or other qualified practitioner with admitting privileges in accordance with State law and hospital policy, who admitted the patient is responsible for the patient during the patient’s stay in the hospital. This responsibility would include developing and entering the discharge summary.
Note:  While others may perform this function, it is clear that they should have participated in the care of the patient AND be recognized to perform this function under the state licensing act.  What if the state is silent?  Then it probably cannot be done by them.

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