CMS SOM App. A, Tag A-1670

The record of

each patient who has been discharged must have a discharge summary that includes

a recapitulation of the patient's hospitalization and…

Interpretive Guidelines §482.61(e)

The medical records, of all patients who have received psychiatric hospital treatment,

must contain a discharge summary. A discharge summary must include a recapitulation

of the patient’s hospitalization, which is a summary of the circumstances and rationale

for admission, and a synopsis of accomplishments achieved as reflected through the

treatment plan. This summary includes the reason(s) for admission, treatment, goals

achieved during hospitalization, a baseline of the psychiatric, physical and social

functioning of the patient at the time of discharge, and evidence of the patient, family,

and/or significant other’s response to the treatment interventions.

The MD/DO or other qualified practitioner, as determined by hospital policy and State

law, with admitting privileges and who admits the patient, is responsible for the patient

during the patient’s stay in the hospital. This responsibility includes developing and

entering the discharge summary into the patient medical record. The discharge summary

includes the patient’s response to the treatment and rehabilitative activity, and discusses

the outcome of the hospitalization, the disposition of the patient, and provisions for

follow-up care. Refer to §482.22 for additional guidance related to medical staff

responsibilities and governing bylaws.

At the request of the responsible MD/DOs, a different MD/DO, psychologist, or other

qualified practitioner who works with the patient’s MD/DO, and who is covering for the

patient’s MD/DO, and who is knowledgeable about the patient’s condition, the patient’s

care during the hospitalization, and the patient’s discharge plans, may write the

discharge summary.

In accordance with hospital policy and 42 CFR §482.12(c)(1)(i), the MD/DO may

delegate writing the discharge summary to other qualified health care personnel such as

nurse practitioners and MD/DO assistants to the extent recognized under State law.

Whether delegated or non-delegated, we would expect the person who writes the

discharge summary to authenticate, date, and time their entry.

Survey Procedures §482.61(e)

• Review a sample of medical records of discharged patients to verify that all

records contain a discharge summary.

• Verify the discharge summary includes (1) the outcome of the treatment and

procedures; (2) the disposition of the case; and (3) provisions for follow-up care.