coordinated fashion. The responsible attending physician or APP shall communicate appropriate medical information to any practitioner and / or any agency, entity or institution to which a patient is referred following discharge from the Hospital.
2. Patient Leaving Hospital AMA. If a patient leaves the Hospital against medical advice, the attending physician Member or other practitioner shall document the patient’ s decision in the medical record.
3. Discharge Summary. For patients who have been in the Hospital for a period of more than 24 hours, the attending physician or other practitioner shall enter a discharge summary within 24 hours of discharge. For uncomplicated patients who have been in the Hospital for less than 24 hours, the attending physician or other practitioner shall enter a discharge note. Newborn patients with no clinical problems do not require a discharge summary regardless of length of stay.
4. Content of Discharge Summary. For stays of twenty-four( 24) hours or longer, a complete discharge summary will be required and will contain at least the following elements:
a. |
reason for Hospitalization, observation, treatment, procedure or |
surgery; |
b. |
procedures performed, including their outcomes and any |
complications, or that none were performed; |
c. |
care, treatment, and services provided; |
d. |
Hospital course; |
e. |
pertinent lab and diagnostic imaging studies; |
f. |
consultations( if applicable); |
g. |
patient’ s condition and disposition at discharge; |
h. |
discharge diagnosis; |
i. |
outcome of Hospitalization relative to condition on admission; |
j. |
discharge instructions( including list of discharge medications); |
k. |
provisions for follow-up care; |
l. |
a list of outstanding medical issues and pending tests at the time of |
discharge that require follow-up; and |
m. |
information provided to the patient and family. |
5. Use of Final Notes in Lieu of a Discharge Summary. For all stays of less than twenty-four( 24) hours, the final progress notes, Emergency Department( ED) notes, clinic notes or other forms of documentation, may serve as the discharge summary provided they contain the following elements:
a. outcome of Hospitalization, observation, treatment, procedure or surgery;
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