Transcript The Discharge Summary: What PCP’s and coders want

The Discharge Summary:
What PCP’s and coders want
J Rush Pierce Jr, MD, MPH
Lenny Noronha, MD
Hospitalist Best Practices Conference
November 20, 2009
Objectives
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Clarify the purpose of the DC summary: 1min
Review the literature, our practice: 5 min
Assess needs of pcp’s, coders, other
readers: 12 minutes
Initiate discussion of UNM Best Practices for
current ward structure: 30 minutes
PLEASE COMPLETE SURVEY DURING THIS
PROGRAM
Purposes of discharge summary
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Accurately record what happened in the
hospital
Assist colleagues with care of patient in the
future (pcp, DC fu clinic, ER, etc)
Concise report for hospital coders in quality
and billing
Assist auditors, demographers, researchers
Are discharge summaries
complete? - Australian study
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80% had chief complaint
40% listed PCP
35% listed pending lab
40% listed complications that occurred in
hospital
80% listed discharge meds
J Qual Cl Pract 2001:21:104
Are discharge summaries timely
and complete? (US meta analysis)
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Only 30% d/c summ
available to PCP at time
of first post discharge
visit
Only 40% have compete
list of discharge meds
50% contain consultants
recs
JAMA 2007; 297:834
Are discharge summaries accurate?
Boston studies
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In pts referred to SNF’s 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?
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JGIM 2009:24:1002
In pts with
outstanding tests,
only 25% DS
recorded any
outstanding test,
and only 13%
recorded all
outstanding tests.
10% outstanding
test were actionable
Do discharge summaries assist
transition with incomplete w/u?
Arch Intern Med 2007;167:1305
Discharge summaries - what do
PCP’s want?
JAMA 2007; 297:834
What do we tell our residents?
(Medical Records sheet)
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Reason for hospitalization (principal
diagnosis)
Secondary diagnoses
Significant findings during hospitalization
Procedures performed
Care, treatment, and services provided
Patient’s condition at discharge
Instructions to the patient and family
What do we tell our residents?
(Survival guide)
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Pt name and MR#
Attending name, service, date of admit, d/c, and
dictation
Admit (primary and secondary) and d/c diagnoses
Procedures and dates
Brief H& P, refer them to full H&P
Hospital course by problem list
Complications and description
D/C meds and doses
F/U with dates and times
Recommendations/precautions
Cc to PCP, any subspecialty service
What do we tell our residents?
(Instructions on Wiki)
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Dates of Admission and Discharge
Discharging Attending, Resident, and Intern
Final Primary and All Secondary Diagnoses
Brief HPI: Presenting problem that precipitated hospitalization with key admission
findings and test results
Brief Hospital Course by Problem - “How we worked it up, how we treated it, what’s
the future plan”
Including key findings, procedure results, and abnormal test results
Sub-Specialist Recommendations
Reconciled Discharge Medication - New or Changed Dose Medications, Continued
Meds from Admission, Stopped Meds
Functional Status at Discharge and Discharge Destination
Follow-up Plan - Follow up Appointment within 2 weeks
Suggested Management Plan
Pending Labs or Test
Any Anticipated Problems and Suggested Interventions with documentation of patient
education (smoking cessation) and understanding
What do coders look for?
PLEASE COMPLETE A SURVEY DURING THIS PROGRAM !
2 separate sets of coders
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Provider Coding
Private company
Take a % of collections
CPC
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Certif professional coder
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Facility Coding
Hospital employees
CCS
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Quality -> UHC
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Certif coding specialist
Expected mortality
Severity of illness
Hospital reimbursement
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MS-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 dx
 Secondary diagnoses
 MCC, CC’s
 POA conditions?
Both groups look for Obs/Inpt Status
MCC/CC
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Announced 2007 by CMS, in place since
10/1/08
MS-DRG’s go into:
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DRG w MCC (major complication/comorbidity)
DRG w CC (complication/comorbidity)
DRG w/o MCC
DRGs w MCCs RAISE EXPECTED MORTALITY!!!
Common Medicine Examples*
MCC
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Acute systolic CHF
Sepsis
Acute kidney injury, ARF
CC
 Systolic CHF
 Uti, urosepsis
 Dehydration
* Complete list on Hospitalist Wiki
Sepsis Reminder
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Bacteremia: asympt lab result
Septicemia: symptoms, but not meeting SIRS
Sepsis: infection c symptoms meeting SIRS,
culture not required
Severe 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 FY2008
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Catheter-associated uti
Pressure ulcer (stage 3 or 4)
Vascular catheter infection
Hosp acquired injuries (falls, etc)
Preventable object left in surgery
Air embolism
Blood incompatibility
CMS “Never Events” IPPS FY2009
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Manifestations of poor glycemic control
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DKA
Nonketotic hyperosmolar/Hypoglycemic coma
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DVT/PE p TKA/THA
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Surgical site infections
 Mediastinitis after CABG
 Bariatric surgery
 Ortho spine/neck/shoulder/elbow
UH Delinquent Records by Medical Staff Services
350
323
300
236
250
Sep-09
200
Oct-09
150
150
Nov-09
0
99
82
100
50
144
69
48
UnitTargets
11
29
1
2
Delinquent Record = DC Summary or H&P 30 days overdue
Discharge summary – questions to
address
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What 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?
HAVE YOU COMPLETED YOUR SURVEY?