The Discharge Summary: What PCP’s and coders want

1. 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

2. Objectives • 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

3. Purposes of discharge summary • 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

4. Are discharge summaries complete? - Australian study • 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

5. Are discharge summaries timely and complete? (US meta analysis) • 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

6. Are discharge summaries accurate?Boston studies • 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)

7. 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

8. Do discharge summaries assist transition with incomplete w/u? Arch Intern Med 2007;167:1305

9. Discharge summaries - what do PCP’s want? JAMA 2007; 297:834

10. What do we tell our residents? (Medical Records sheet) • 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

11. What do we tell our residents? (Survival guide) • 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

12. What do we tell our residents? (Instructions on Wiki) • 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

13. What do coders look for? PLEASE COMPLETE A SURVEY DURING THIS PROGRAM !

14. 2 separate sets of coders Provider Coding Facility Coding Hospital employees CCS Certif coding specialist Quality -> UHC Expected mortality Severity of illness Hospital reimbursement MS-DRG • Private company • Take a % of collections • CPC • Certif professional coder

15. What to coders look for in the dc summary? UNMMG (provider) UNMH (facility) Was it done? Was it billed? Principle dx Secondary diagnoses MCC, CC’s POA conditions? • Was it done? • Was it billed? • > 30 min? Both groups look for Obs/Inpt Status

16. MCC/CC • Announced 2007 by CMS, in place since 10/1/08 • MS-DRG’s go into: • DRG w MCC (major complication/comorbidity) • DRG w CC (complication/comorbidity) • DRG w/o MCC DRGs w MCCs RAISE EXPECTED MORTALITY!!!

17. Common Medicine Examples* MCC CC Systolic CHF Uti, urosepsis Dehydration • Acute systolic CHF • Sepsis • Acute kidney injury, ARF * Complete list on Hospitalist Wiki

18. 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 Sepsis Reminder

19. CMS “Never Events” IPPS FY2008 • 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

20. CMS “Never Events” IPPS FY2009 • Manifestations of poor glycemic control • DKA • Nonketotic hyperosmolar/Hypoglycemic coma • DVT/PE p TKA/THA • Surgical site infections • Mediastinitis after CABG • Bariatric surgery • Ortho spine/neck/shoulder/elbow

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

22. Discharge summary – questions to address • 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?