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Discharge documentation

  1. Default Discharge documentation
    Medical Coding Books
    The hospital that we do heart cath procedures says that it is required by medicare to dictate all discharge summaries. Regardless of whether the patient is inpatient, outpatient or observation. We currently handwrite all of our discharge summaries. Is it an actual requirement to dictate discharge summaries or is the hospital just wanting everyone to dictate?

  2. #2
    When I worked in the hospital setting our physicians also had to dictate a discharge summary. I am not sure if that is a medicare requirement you can check on CMS website and ask that question or look in the manuals online or paper manual. Good luck

  3. Default
    Personally, if the hospital is telling you, or the provider, that dictated discharge summaries are required by Medicare, I'd ask the hospital to provide me, or the provider, with supporting documentation of that.

    There is documentation in WPS Part B to support medical record documentation in the formats of:

    Dictated and transcribed;


    Hand-written; or


    That information may be found at:

    Chapter 5, Evaluation and Management Documentation

    Hope this helps!


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