Hailey Tran
A hospital discharge summary is a crucial document that outlines a patient's hospital stay and provides recommendations for their post-discharge care. It serves as a communication tool to ensure continuity of care as the patient transitions to a new care setting. As a patient, understanding your hospital discharge summary is essential for your ongoing health management. This article will discuss the key components of a discharge summary, the process for requesting it, and the rights patients have to access their medical records. Additionally, we will explore the different formats discharge summaries can take and provide examples of resources you can use to create an effective summary.
| Characteristics | Values |
|---|---|
| Who can request | The patient or their personal representative/caregiver with written permission |
| How to request | In person, by phone, by email, by letter, via the patient portal, or by filling out a form |
| Time taken to process request | 30-60 days |
| Contents of discharge summary | Description of patient's primary presenting condition, description of patient's initial presentation to the hospital, primary diagnoses, description of events occurring during the hospital stay, description of surgical, medical, or other specialty consults experienced as an inpatient |
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What You'll Learn
Understanding what a discharge summary is
A discharge summary is a clinical report prepared by health professionals that outlines the details of a patient's hospitalisation. It is a crucial document that promotes patient safety, enhances care continuity, and improves communication between patients and providers. This document often serves as the only form of communication that accompanies a patient to their next care setting.
The Joint Commission has established standards outlining the components that should be included in a hospital discharge summary. These components are:
- Reason for hospitalisation
- Significant findings
- Procedures and treatment provided
- Patient's discharge condition
- Patient and family instructions (as appropriate)
- Attending physician's signature
While these components provide a strong foundation, hospitals may include additional elements to improve patient safety. For instance, the Transitions of Care Consensus Conference (TOCCC) recommended including a description of the patient's primary presenting condition and their initial presentation to the hospital.
A well-crafted discharge summary ensures clinical accuracy, reduces the possibility of clinical errors, and enhances care continuity. It enables seamless information transfer between the hospital care team and aftercare providers, facilitating a swift and appropriate response to the patient's needs.
Overall, a discharge summary is an essential tool for effective patient care and safe transitions between care settings.
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Knowing what to include in a discharge summary
A discharge summary is a clinical report prepared by a health professional after a hospital stay or series of treatments. It is a legal document that serves as a form of communication between the hospital care team and aftercare providers, such as the patient's GP. It is important to include the correct information in a discharge summary to ensure patient safety and effective aftercare.
The Joint Commission mandates that six components be present in all U.S. hospital discharge summaries. These components are also noted as requirements in the National Quality Forum's Safe Practices for Better Healthcare. The six components are:
- Description of the patient's primary presenting condition and/or a description of the patient's initial presentation to the hospital, including the initial diagnostic evaluation.
- Primary diagnoses.
- Description of the events occurring to a patient during their hospital stay, including surgical, medical, or other specialty consultations the patient experienced as an inpatient.
- Reason for hospitalization, including the chief complaint and/or history of the patient's present illness.
- Significant findings, defined as primary diagnoses.
- Patient's discharge condition.
In addition to these six components, other information that may be included in a discharge summary are the patient's full name and preferred name, the details of the patient's GP, and the discharge destination, such as whether the patient is returning home or going to a residential care home. It is also important to include a summary of the patient's presenting symptoms and signs, as well as any salient investigations performed during their admission.
To make the discharge summary accessible to the patient, it is recommended to include a section that summarises the key information of the patient's hospital stay in patient-friendly language. This section should be written in plain English, with short sentences and one topic per paragraph. Technical terms should be explained, and any instructions for the patient should reiterate what was explained before discharge.
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Knowing your rights to access medical records
As a patient, you have a right to access your medical records. This is guaranteed by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which protects the privacy and security of your health information. You can request your medical records by visiting the facility in person, contacting them by phone, visiting their website, or visiting your patient portal.
HIPAA grants you the right to decide who gets to see your medical information and when. However, there are exceptions. For example, your healthcare provider can share your medical records without your consent in specific situations, such as when enrolling in an insurance plan or applying for disability benefits. You also have the right to request changes to incorrect information in your medical records.
When requesting your medical records, be aware that your healthcare provider has the right to charge a "reasonable, cost-based fee" for supplying them. This fee should only cover the costs of making and sending the copies. You may also have to wait for a period, typically around 30 days, for your request to be processed.
In some cases, you may encounter challenges in accessing your medical records. If you feel that your healthcare provider is purposefully withholding records, make sure to submit your request in writing and keep a copy of the original request. This creates a paper trail, which can be useful if you need to report any issues or take legal action. Additionally, each state has its own regulations on medical record retention requirements, so be sure to familiarize yourself with the laws in your specific state.
If you are requesting medical records on behalf of someone else, you may need written permission or power of attorney. If you are unclear about your right to receive someone else's records, it is best to contact the health information department or receptionist at the facility from which you are requesting the records.
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How to request medical records
To request your medical records, you should first check if your healthcare provider has an online patient portal. This is a secure website where patients can make appointments, contact their provider, and sometimes access certain health information, like a list of immunizations. If your provider has a patient portal, you may be able to request your medical records through it.
If your healthcare provider does not have a patient portal, or if the health information you need is not available through the portal, you can try other methods of requesting your records. Check your provider's website, as information about how to get your records may be available there. If not, you can request your records by filling out a form, sending an email, or mailing or faxing a letter to your provider.
Your provider may require you to complete a release form to document your authorization to access the records. This may be called a health or medical record release form, or request for access. You may also need to pay a fee for copies of your records, although there is usually no charge for records sent directly to a healthcare provider or requested by Medicare or other public assistance programs. If you are requesting records for someone other than your child, you may need to provide legal paperwork giving you the right to access their health information.
When making a request, be sure to include your full name, date of birth, patient identification number (PIN), or medical record number (MRN). If you are not using a form, also include your address, phone number, and a secure fax number or email address where the provider can send you the records. Clearly indicate where and to whom you would like the records sent, and give at least three weeks' notice if possible. After submitting your request, follow up with a telephone call to ensure that it was understood, and check again at least a week before your first appointment to make sure the records have arrived.
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How to access medical records
As a patient, you have the right to access your medical records, regardless of the reason. You may need to access your medical records to get a second opinion, for example. You can request your medical records by visiting the facility in person, contacting them by phone, visiting their website, or visiting your patient portal. Many healthcare providers have Electronic Health Records systems (EHRs) that provide patient portals where you can access your medical records. You can also request your medical records via email or letter.
If you are requesting records on someone else's behalf, you must have written permission or power of attorney. If you are requesting records about a deceased patient, you must be an executor of their estate or have permission from the executor. If there is no executor, you can petition to become one through a probate court.
When accessing your medical records, you may need to clarify what specific information you are requesting. You have access to all or part of your medical record, including billing statements, discharge summaries, lab reports, operative reports, physician office records, radiology and/or MRI images, and rehabilitation records. If you are requesting radiology reports and images, you may need to complete and sign a release of information form.
If you feel that the facility is purposefully withholding your records, make sure to make your request in writing and keep a copy of the original request. That way, you have a paper trail if you need to report anything or take legal action. Additionally, you should not be charged a fee for accessing your medical records or for the transfer of your records to another facility.
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Frequently asked questions
You can request a discharge summary from a hospital by visiting the facility in person, contacting them by phone, visiting their website, or visiting your patient portal.
You will need to provide written permission or power of attorney if you are requesting records on someone else's behalf. If you are requesting your own records, you will need to provide identification and may need to complete a release of information form.
The facility cannot charge you for searching for, retrieving, or digitally sending your medical records. They also cannot charge you for any outstanding medical bills or debt accompanying the records.
Depending on the state, providers have 30 to 60 days to process a request, and your wait time shouldn't exceed 90 days.
