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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