CMS SOM App. A, Tag A-0810

transmission of the patient’s necessary medical information.

(b) The hospital must discharge the patient, and also transfer or refer the patient where

applicable, along with all necessary medical information pertaining to the patient’s current

course of illness and treatment, post-discharge goals of care, and treatment preferences, at the

time of discharge, to the appropriate post-acute care service providers and suppliers, facilities,

agencies, and other outpatient service providers and practitioners responsible for the patient’s

follow-up or ancillary care.

Interpretive Guidelines §482.43(b)

For all patients being discharged, referred, or transferred from the hospital, the hospital must

provide at the time of discharge all of the patient’s medical information that is pertinent and

appropriate to post hospital providers and suppliers, facilities, agencies and outpatient

providers and practitioners. Post hospital providers, suppliers, and practitioners include but are

not limited to skilled nursing facilities, nursing facilities, home health agencies, hospice

agencies, mental health agencies, dialysis centers, suppliers of durable medical equipment,

suppliers of physical and occupational therapy, physician offices, etc. which offer post-acute

care services that address the patient’s post-hospital needs identified in the patient’s discharge

planning evaluation. They may also include other hospitals to which a patient is transferred for

follow-up care, such as rehabilitation hospitals, long term care hospitals, or even other short-term acute care hospitals.

The necessary medical information will be related to the patient’s current course of illness and

treatment, goals of post-hospital care, and patient treatment preferences. The goal of providing

this information is to assist the post hospital providers with medical information that will allow

for a safe transition from acute care settings.

The “medical information” that is necessary for the transfer or referral may include, but is not

limited to:

• Brief reason for hospitalization and patient history (or, if hospital policy requires a

discharge summary for certain types of outpatient services, the reason for the encounter)

and principal diagnosis;

• Brief description of hospital course of treatment;

• Patient’s condition at discharge, including cognitive, functional, and behavioral status

and social supports needed (including any mental health or substance treatment

supports);

• Medication list (reconciled to identify changes made during the patient’s hospitalization)

including prescription and over-the-counter medications and herbal. (Note, an actual list

of medications needs to be included in the discharge information, not just a referral to an

electronic list available somewhere else in the medical record.);

• List of allergies (including food as well as drug allergies) and drug interactions;

• Pending laboratory work and test results, if applicable, including information on how the

results will be furnished.

For patients discharged home:

• Brief description of care instructions reflecting training provided to patient and/or

caregiver(s);

• If applicable, list of all follow-up appointments with practitioners with which the patient

has an established relationship and which were scheduled prior to discharge, including

who the appointment is with, date and time.

• If applicable, referrals to potential primary care providers, such as health clinics, if

available, for patients with no established relationship with a practitioner.

• Additional post-acute or community health service referrals;

For transfer to other facilities, necessary medical information also includes, but is not limited to,

a copy of the patient’s advance directive, if the patient has one; and contact information for the

hospital and nursing staff with knowledge of the patient in the event the receiving facility needs

to communicate regarding patient care needs.

Survey Procedures §482.43(b)

• Verify that all necessary medical information pertaining to the patient’s current course of

illness and treatment, post-discharge goals of care, and treatment preferences were provided

to the appropriate post-acute care service providers and suppliers, facilities, agencies, and

other outpatient service providers and practitioners responsible for the patient’s follow-up or

ancillary care at the time of the patient’s discharge.