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The Discharge Summary: What PCPs and coders wantJ Rush Pierce Jr, MD, MPHLenny Noronha, MDHospitalist Best Practices ConferenceNovember 20, 2009

ObjectivesClarify the purpose of the DC summary: 1minReview the literature, our practice: 5 minAssess needs of pcps, coders, other readers: 12 minutesInitiate discussion of UNM Best Practices for current ward structure: 30 minutes

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Purposes of discharge summaryAccurately record what happened in the hospitalAssist colleagues with care of patient in the future (pcp, DC fu clinic, ER, etc)Concise report for hospital coders in quality and billingAssist auditors, demographers, researchers

Are discharge summaries complete? - Australian study80% had chief complaint40% listed PCP35% listed pending lab40% listed complications that occurred in hospital80% listed discharge meds

J Qual Cl Pract 2001:21:104

Are discharge summaries timely and complete? (US meta analysis)Only 30% d/c summ available to PCP at time of first post discharge visitOnly 40% have compete list of discharge meds50% contain consultants recs

JAMA 2007; 297:834

Are discharge summaries accurate?Boston studiesIn pts referred to SNFs medication discrepancy between DCs and transfer form identified in 52% of admissions. CV drugs, opiates, psych meds, hypoglycemics, antibiotics, and anticoags accounted for 50% of descrepancies (JGIM 2009;24:630)In pts discharged to rehab on coumadin, only 16% had info about indication, duration, monitoring, and follow-up (Jt Comm Qual Patient Saf 2008;34:460)

Do discharge summaries assist transition with outstanding tests?In pts with outstanding tests, only 25% DS recorded any outstanding test, and only 13% recorded all outstanding tests. 10% outstanding test were actionable

JGIM 2009:24:1002

Do discharge summaries assist transition with incomplete w/u?

Arch Intern Med 2007;167:1305

Discharge summaries - what do PCPs want?

JAMA 2007; 297:834

What do we tell our residents? (Medical Records sheet) Reason for hospitalization (principal diagnosis)Secondary diagnosesSignificant findings during hospitalizationProcedures performedCare, treatment, and services providedPatients condition at dischargeInstructions to the patient and family

What do we tell our residents? (Survival guide) Pt name and MR#Attending name, service, date of admit, d/c, and dictationAdmit (primary and secondary) and d/c diagnosesProcedures and datesBrief H& P, refer them to full H&PHospital course by problem listComplications and descriptionD/C meds and dosesF/U with dates and timesRecommendations/precautionsCc to PCP, any subspecialty service

What do we tell our residents? (Instructions on Wiki) Dates of Admission and DischargeDischarging Attending, Resident, and InternFinal Primary and All Secondary DiagnosesBrief HPI: Presenting problem that precipitated hospitalization with key admission findings and test resultsBrief Hospital Course by Problem - How we worked it up, how we treated it, whats the future planIncluding key findings, procedure results, and abnormal test resultsSub-Specialist RecommendationsReconciled Discharge Medication - New or Changed Dose Medications, Continued Meds from Admission, Stopped MedsFunctional Status at Discharge and Discharge DestinationFollow-up Plan - Follow up Appointment within 2 weeksSuggested Management PlanPending Labs or TestAny Anticipated Problems and Suggested Interventions with documentation of patient education (smoking cessation) and understanding

What do coders look for?

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2 separate sets of coders Provider CodingPrivate companyTake a % of collectionsCPCCertif professional coder

Facility CodingHospital employeesCCSCertif coding specialistQuality -> UHCExpected mortalitySeverity of illnessHospital reimbursementMS-DRG

What to coders look for in the dc summary?UNMMG (provider)Was it done?Was it billed?> 30 min?UNMH (facility)Was it done?Was it billed?Principle dxSecondary diagnosesMCC, CCsPOA conditions?Both groups look for Obs/Inpt Status

MCC/CCAnnounced 2007 by CMS, in place since 10/1/08MS-DRGs go into:DRG w MCC (major complication/comorbidity)DRG w CC (complication/comorbidity)DRG w/o MCC

DRGs w MCCs RAISE EXPECTED MORTALITY!!!

Common Medicine Examples*MCCAcute systolic CHFSepsisAcute kidney injury, ARFCCSystolic CHFUti, urosepsisDehydration* Complete list on Hospitalist Wiki

Sepsis ReminderBacteremia: asympt lab resultSepticemia: symptoms, but not meeting SIRSSepsis: infection c symptoms meeting SIRS, culture not requiredSevere sepsis: with organ dysfx (i.e. AKI, hepatitis, altered mental status)Septic shock: with hypotension not responsive to initial IV fluids

CMS Never Events IPPS FY2008Catheter-associated utiPressure ulcer (stage 3 or 4)Vascular catheter infectionHosp acquired injuries (falls, etc)Preventable object left in surgeryAir embolismBlood incompatibility

CMS Never Events IPPS FY2009Manifestations of poor glycemic controlDKANonketotic hyperosmolar/Hypoglycemic comaDVT/PE p TKA/THASurgical site infections Mediastinitis after CABG Bariatric surgery Ortho spine/neck/shoulder/elbow

Delinquent Record = DC Summary or H&P 30 days overdue

Discharge summary questions to addressWhat should our model discharge summary look like?Do we need a standardized DCS time out?How extensively should faculty modify resident d/c summaries?Should all summaries be done on day of dc?Who does it when the intern is off/clinic?

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