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MEDICAL CITY NORTH HILLS
CONTENT OF RECORD: DISCHARGE SUMMARY
Tag No.: A0468
Based on interview and record review, on 03/03/2019 the hospital failed to incorporate a discharge summary with outcome of the hospitalization and disposition of care in the medical record for 1 of 1 patient (Patient #1) that was admitted on 12/17/2019 and was discharged on 12/21/2019.
Findings included:
Patient #1 was admitted as an inpatient in the medical surgical floor after a surgical procedure on 12/17/2019. Patient #1 was discharged on 12/21/2019.
Emails and phone calls were exchanged on the morning of 03/04/2020. The patient's discharge summary was requested on 03/04/2020 since the discharge summary provided to the surveyor on 03/03/2020 was a "Brief Discharge Note." The note included discharge instructions and contact information to schedule a follow-up appointment with the surgeon. Personnel #1 stated medical records department did not find the patient's discharge summary. Personnel #1 was asked if the hospital's policy and procedure was to complete a discharge summary within 30 days after a patient discharge. Personnel #1 replied yes. Personnel #1 was asked where the patient was discharged to. She replied home.
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based on interview and record review, on 03/03/2020 the hospital failed to include in the medical record a final diagnosis and/or diagnoses within 30 days following discharge, citing 1 of 1 patient (Patient #1) that was admitted on 12/17/2019 and discharged on 12/21/2019.
Findings included:
Patient #1 was admitted as an inpatient in the medical surgical floor after a surgical procedure on 12/17/2019. Patient #1 was discharged on 12/21/2019. A discharge summary was not included in Patient #1's medical record, hence a final diagnosis and/or diagnoses was not documented.
Emails and phone calls were exchanged on the morning of 03/04/2020. The patient's discharge summary was requested on 03/04/2020 since the discharge summary provided to the surveyor on 03/03/2020 was a "Brief Discharge Note." The note included discharge instructions and contact information to schedule a follow-up appointment with the surgeon. Personnel #1 stated medical records department did not find the patient's discharge summary. Personnel #1 was asked if the hospital's policy and procedure was to complete a discharge summary within 30 days after a patient discharge. Personnel #1 replied yes.