A signature (electronic or physical) of the attending physician on the discharge summary. A discharge summary plays a crucial role in patient safety after leaving the hospital. A report from Advances in Patient Safety states that “hospital discharge summaries serve as primary documents that communicate a patient`s care plan to the postclinical care team. Often, the discharge summary is the only form of communication that accompanies the patient to the next nursing setting. It is widely accepted that high-quality discharge summaries are essential to promote patient safety during the transition between care facilities, particularly during the first postclinical phase. In a study published in the Journal of the American Board of Family Medicine, the providers surveyed said they only had “. had a [post-discharge] summary available in 0% to 40% of cases, 41.4% noted availability in 41% to 80% of cases, and 31.1% >80% of the time”. Documentation that provides an idea of how the patient is discharged or their state of health at the time of discharge. While these six components can serve as a solid foundation for what your hospital should address in its discharge summary, consider whether it`s worth including other components that can help improve patient safety. While the development of electronic solutions has helped improve patient information communication from one healthcare facility to another, the use of these resources does not negate the importance and responsibility of a hospital in creating a discharge summary. A report published in the Joint Commission Journal on Quality and Patient Safety states: “. Incomplete discharge summaries remain a common problem that can contribute to poor post-hospital outcomes. Detailed information on these six elements of mandatory discharge summary can be found here.
It should be noted that while full and accurate discharge summaries are essential for follow-up, their availability is equally crucial for primary care providers. In May 2020, the Centers for Medicare & Medicaid Services (CMS) released a final rule for interoperability and patient access on the Federal Register that applies to hospitals, psychiatric hospitals, and critical access hospitals. In response to this final regulation, the Joint Committee created new requirements for notifications of approval, discharge and transfer, which were issued on 1. May 2021. As a for the Record report points out, the Joint Commission requires that all discharge summaries include six high-level elements, which are also listed as requirements in the National Quality Forum`s Safe Practices for Better Health Care. The Joint Committee regularly updates its accreditation requirements. As part of this process, we seek input from healthcare professionals and others with knowledge in a variety of environments. You can help by reading and commenting on suggested requirements related to your area of expertise. So what should your hospital ensure that it includes in its discharge summary? Would you like to create or update a summary of hospital discharges? There is no need to reinvent the wheel. You can emulate hospital discharge summaries used by other organizations. Here are some resources that may be helpful to you: The previously mentioned “Progress in Patient Safety” report shares these components and includes a consensus definition created by two physicians and a geriatric nurse. for everyone.
These are summarized as follows: A set of standards you should consider came from the Transitions of Care Consensus Conference (TOCCC), a meeting convened by the American College of Physicians, the Society of General Internal Medicine, and the Society of Hospital Medicine (SHM), with representatives of emergency medicine. As noted in an article in the Journal of General Internal Medicine, the TOCCC has proposed a minimum set of data elements that should be included in the transition dataset (which overlap with the components described above). TOCCC also recommended additional elements for an “ideal transition recording”. The Joint Commission`s standards help you develop strategies to address the most complex issues and identify key weaknesses in patient care. Standards look at various aspects of your patient care process and ensure a comprehensive review of your patient care process. The accreditation and certification standards manuals are available in printed and electronic form and can be purchased from the resources® of the Joint Commission. If not, please ask us how we could improve this response. Gather the data you need to gain insights that will help you reduce risk, increase efficiency, and improve your organization`s performance.
Joint Commission Requirements is a free list of all revised standards published in Joint Commission Perspectives that have come into effect since the last publication of the Accreditation and Certification Manual. Answers to frequently asked questions about standards can be found in the Standards Interpretation section. The study concluded that there are significant opportunities to improve the timeliness and availability of the PDS through a combination of process redesign and the use of electronic health records. Consult the pre-publication standards. These changes will be published in the standard version dated July 1, 2021. Pre-publication standards are used to communicate upcoming changes to our standards and performance elements (PEs). Reports are published before publication in E-dition and detailed manuals….