CMS SOM App. A, Tag A-1671

discharge summary that includes]… recommendations from appropriate services

concerning follow-up or aftercare as well as…

Interpretive Guidelines §482.61(e)

The discharge summary must include recommendations for follow-up or aftercare, that

should include any post-hospital appointments, plans for post-hospital care, and describe

how post-hospital patient care needs are to be met.

The summary should identify the recommended outpatient and community mental health

resources in the geographical area where the patient is being discharged, and the

coordinated services to be provided by the aftercare facilities to ensure effective

continuity of care.

The patient’s discharge planning process should identify and attempt to address potential

problems after discharge and suggested means for intervention, (e.g., accessibility and

availability of community resources and support systems, including transportation, and

special problems related to the patient’s functional ability to participate in aftercare

planning such as homelessness and lack of family/significant other support systems).

The discharge summary should contain a discussion related to recommendations to the

next treatment provider for patient-specific issues/problems that may arise after

hospitalization.

Examples of what should be included in in the discharge summary regarding follow up or

aftercare include, but are not limited to the following:

• A description of arrangements for treatment and other community resources

for the provision of follow-up services;

• A plan outlining follow-up psychiatric care, medical/physical treatment and

the medication regimen as applicable;

• A description of community housing/living arrangement(s) available in the

community/area where the patient is being discharged to;

• A description of the recommended and/or actual planned involvement of

family and significant others with the patient after discharge; and

• A list of discharge medications including dosage, frequency and quantity.

Survey Procedures §482.61(e)

• Review a sample of medical records and verify the discharge summary follow up

care recommendations were included in the discharge summary.

• Review the discharge plan to verify that it identifies appropriate aftercare for

follow-up treatment.

• Verify that discharge related documents are made available to the patient,

patient’s representative, community treatment source and/or any other aftercare

service provider, as appropriate, who may need the record for continuity of care.

• Verify that the aftercare plan was communicated to the post-hospital treatment

entity, when indicated.

• Review the discharge summary to determine if it contains a plan for follow-up

psychiatric care, medical/physical treatment and the medication regimen as

applicable.