Discharge documentation and coding

The problem

Discharge is a bottleneck made of documentation. The summary, the coding and the follow-up arrangements are three jobs, often done by different people at different times, each re-reading the same admission from the start.

The steps

1. Patient record, covering the admission.
2. Sources, pointed at your discharge standards if your organisation has them written down.
3. Ask Rhazes to summarise the admission: why they came in, what was found, what was done, what changed about their medication and why, what is still outstanding, and what the community team needs to do next.
4. Document, using the Discharge Summary template.
5. Create tasks for what discharge generates: the TTO to check, results still pending at discharge, the letter to send.
6. Output for checking.

Coding it

Run coding on the same chat afterwards. Each code comes with the evidence from the record that supports it, and the set can be exported as a PDF for submission or audit. See Coding a chat and Exporting coding evidence.

Doing it from the same material as the summary is the point: the codes and the narrative describe the same admission, because they were produced from the same source.

What to check

Medication changes above everything else. A discharge summary that gets medication wrong causes harm in the community, and it is the section where an omission is hardest to spot, because something missing leaves no trace on the page.

Then check what is described as outstanding. A result still pending at discharge that nobody carries forward is a classic way for something to be lost between teams.