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Centers for Medicare and Medicaid Services mandated elements of the discharge summary

Centers for Medicare and Medicaid Services mandated elements of the discharge summary
  • Demographic information, including but not limited to name, sex, date of birth, race, ethnicity, and preferred language
  • Contact information for the practitioner responsible for the care of the patient and the patient's caregiver/support person(s)
  • Advance directives, if applicable
  • Course of illness/treatment
  • Procedures
  • Diagnoses
  • Laboratory tests and the results of pertinent laboratory and other diagnostic testing
  • Consultation results
  • Functional status assessment
  • Psychosocial assessment, including cognitive status
  • Social supports
  • Behavioral health issues
  • Reconciliation of all discharge medications with the patient's pre-hospital admission/registration medications (both prescribed and over-the-counter)
  • All known allergies, including medication allergies
  • Immunizations
  • Smoking status
  • Vital signs
  • Unique device identifier(s) for a patient's implantable device(s), if any
  • Patient's goals and treatment preferences
  • All other necessary information to ensure a safe and effective transition of care that supports the post-discharge goals for the patient*
* In addition to these proposed minimum elements, the Centers for Medicare and Medicaid Services proposes that necessary information must also include a copy of the patient's discharge instructions, the discharge summary, and any other documentation that would ensure a safe and effective transition of care, as applicable.
Reproduced from: Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs; Revisions to requirements for discharge planning for hospitals, critical access hospitals, and home health agencies, and hospital and critical access hospital changes to promote innovation, flexibility, and improvement in patient care. Federal Register 2019; 84:51836. https://www.federalregister.gov/d/2019-20732 (Accessed February 12,2025).
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