Yes, this is a problem. Post-op' discharge summaries normally review diagnosis, surgery, post-op' care and a follow-up meeting but not necessarily a care plan. And I have seen others in which a care plan was critical ( stage four cardiomyopathy patient, for example) but not provided. In this case the patient did not know his diagnosis and thought the only problem was the pacemaker whose contacts had to be replaced.

The answer is institutional. Perhaps at a grand rounds the nature of the discharge summary needs to be discussed and the specifics of all need to be precisely defined, including future care plans. Specific departments may draw up a quick check-list and form that physicians or their assistants can fill in before dicharge including specific (post-op' review) and follow-up care (physio', social worker, counseling, etc.) are briefly but clearly described.

Additionally what Tom Koch wrote, in my hospital, there is a team which is responsible for assessing the completeness and quality of Medical Records (MR). The common omission is also the treatment plan and it's frequent revision. How to motivate physicians? If the hospital culture is pro documentation, just publish how many MR by a physician is not completed. They will be ashamed in front of their colleagues. If the culture is different, than the problem is much more serious. Either just pressure by frequent complaining or financial incentives - if possible. If not, other incentives (conferences, etc.)

It isn't the prescribers, it is the discharge planners who fail to send the appropriate information to the appropriate follow up agency.

I often have to call the in-patient hospital and ask someone to tell me what meds were ordered, if a LAI was given/when/dose, copy of labs, etc. It is really sad. All I seem to get is papers with "how to quit smoking", "what to do if suicidal", etc. instead of information, that I need.

We need a universal EHR so we can tap into labs, medications, consults from specialists, test results, etc. Nothing is integrated and it is sad. Also, REASON for admission.

When I work out-patient ER Psych, I write a fast letter letting the ER and Psych provider know my concerns, copy of my brief assessment, and petition/cert.

I hope your research has an impact.

Discharge summary is seperate from assessment because discharge instructions are applied after the progress of patient so that patient can follow for further advise.

For clinical coding purposes, the discharge summary written and duly authenticated by the attending physician is consulted by the coder (please note that coding is done after the patient might have been discharged via the different modes of disposition). Where you have a single condition identified, as provisional, and no new facts emerge until the patient is discharged, that same condition will be assigned the ICD code. But if there is a change, the amended condition recorded by the attending physician is coded. In a situation where there are multiple diagnosis, the physician must indicate the one that qualifies to be principal, and the others are indicated either as secondary diagnoses or complications (whichever be the case). The coder assigns the ICD-10 codes to all the diagnoses as indicated. Where there is not enough information, the coder shall prepare a physician query (in line with policy of the facility), requesting for further details that will aid in identifying the diagnoses rightly and in assigning correct codes to them.

Therefore, the absence of a discharge summary may hamper the quality of coding, and this may result into all forms of error that may affect billing and reimbursement, medical research, planning, and other uses for which the patient records may put.