Question

Evaluate the following discharge summary compared to CMS regulations and recommend additional element or elements needed to meet CMS regulations?

Discharge Summary

Discharge Date: 8/1/2017

Pertinent History: The patient is a 34-year-old female admitted through the ER on 7/24/2017 with severe, stabbing, low-back pain and inability to urinate. The patient has a long history of pelvic inflammatory disease, with three surgical episodes to remove implants. CT scan revealed a mass in the area of the kidneys.

Hospital Course: The patient was admitted, prepped, and taken to surgery. Exploratory laparotomy revealed an area of pelvic inflammatory disease involving both kidneys in dense adhesions. Cultures indicate chlamydia. Both ureters were almost totally blocked. Dense adhesions were painstakingly taken down. This was done very carefully and requires several hours of surgery. Care was taken not to sever the kidneys or ureters. Intercede adhesion barrier was applied.

Postoperatively, the patient was pain free.

Discharge Instructions: The patient was discharged home.

Diagnosis: Severe pelvic adhesions, chlamydia infection.

Jim Mahamom, M.D. (Electronically signed 8/10/2017)

Answer 1

In the given discharge summary, there is a need to add certain elements according to CMS guidelines.

Discharge summary according to CMS guidelines should have the total hospital stay details, along with the discharge diagnoses , Discharge medications, Discharge disposition, Discharge education , Follow up care etc.

But the discharge summary given does not have clear hospital course mentioned.It has only regarding the operative procedure performed.This does not have clear diagnostic conditions detected at the time of discharge instead they only mentioned as patient is free from pain.Mentioned diagnosis in the report stated as only "Diagnosis", which is not clear whether it is of discharge diagnosis or the existing previous one.There is no prescribed medications list or the medications that to be continued or discontinued at the time of discharge.No details if education or followup mentioned in the given discharge summary.These elements makes the discharge summary complete according to CMS guidelines.