Patient Discharge Summary Sample

Standard Operating Procedure: Patient Discharge Summary (PDS) Generation

1. Document Control & Revision History

2. Executive Summary & Scope

This procedure mandates the clinical and administrative requirements for the generation of a Patient Discharge Summary (PDS). The objective is to ensure continuity of care, mitigate readmission risks, and maintain compliance with Joint Commission (TJC) standards and CMS Conditions of Participation.

Scope: Applies to all attending physicians, resident staff, and discharge planners across all inpatient acute care units. The process commences upon the physician’s formal "Order for Discharge" and concludes upon successful transmission of the document to the patient’s Primary Care Provider (PCP) and the patient/caregiver portal.

3. Prerequisites & Tool Requirements

• Electronic Health Record (EHR) Access: Full clinical write-access to the facility’s current EHR instance (e.g., Epic/Cerner/Meditech).
• Software: Dictation software (integrated) or secure mobile clinical documentation platform.
• Certifications: Current NPI-linked clinical credentials verified by the Medical Staff Office.
• Safety PPE: Not applicable for digital processing; standard hospital hygiene protocols apply when accessing physical patient charts in restricted zones.
• System Integration: Active Health Information Exchange (HIE) gateway link for external PCP transmission.

4. Roles & Responsibilities (RACI Matrix)

5. Step-by-Step Operational Procedure

Phase I: Clinical Data Synthesis

• Verify "Discharge Order" is timestamped and active in the EHR.
• Review all diagnostic laboratory, imaging, and pathology reports finalized post-admission.
• Reconcile current inpatient medication list against pre-admission home medications.

Phase II: Documentation Drafting

• Generate standard PDS template via EHR "Discharge Navigator."
• Populate mandatory fields: Admission/Discharge Dates, Discharge Diagnosis (ICD-10-CM), and Principal Procedures (CPT).
• Summarize hospital course with emphasis on complications and deviations from the initial care plan.
• List discharge medications clearly, noting any additions, deletions, or dosage changes with explicit rationale.

Phase III: Verification & Transmission

• Execute "Medication Reconciliation" audit tool; resolve all EHR-flagged discrepancies.
• Attach patient-facing education materials (Condition-specific, follow-up instructions).
• Perform electronic signature and final review.
• Trigger automated HIE transmission to the patient’s designated PCP.

6. Quality Assurance & Verification Criteria

Audits are conducted weekly by the HIM department based on the following benchmarks:

1. Completeness Threshold: 100% of PDS must include follow-up appointment time/date/location.
2. Timeliness Benchmark: PDS must be finalized within 24 hours of patient departure.
3. Accuracy Tolerance: 0% tolerance for medication dosage errors; 95% threshold for diagnosis coding accuracy.
4. Content Verification: Summary must include a "Pending Test Results" section if any labs were incomplete at the time of discharge.

7. Practical Troubleshooting Scenarios

Scenario A: Incomplete Diagnostic Result at Time of Discharge

• Issue: Critical lab or imaging result is pending at the point of physical discharge.
• Correction: Physician must document the specific pending test in the "Follow-up Requirements" section. The system must be set to "Alert Pending" for the primary clinician; the patient must be briefed on how they will be notified of results within 48 hours.

Scenario B: Medication Reconciliation Mismatch (EHR/Pharmacy)

• Issue: Conflict between the EHR medication list and the patient’s external pharmacy history (Surescripts feed).
• Correction: Do not proceed with automated generation. The clinician must conduct a telephonic verbal confirmation with the patient or caregiver to confirm home medication compliance before modifying the discharge list.

Scenario C: HIE Transmission Failure

• Issue: The EHR gateway reports a "Failed Transmission" to the primary care provider.
• Correction: Administrative staff must manually print/secure-fax the PDS to the PCP’s verified office number and document the fax receipt within the EHR activity log within 4 business hours.