Question

Analyze the following discharge summary compared to CMS regulations. What element or elements are missing? Discharge Summary Discharge Date: 8/1/2017 Pertinent History: The patient is a 34-year-old female admitted through the ER on 7/24/2017 with severe, stabbing, low-back pain and inability to urinate. The patient has a long history of pelvic inflammatory disease, with three surgical episodes to remove implants. CT scan revealed a mass in the area of the kidneys. Hospital Course: The patient was admitted, prepped, and taken to surgery. Exploratory laparotomy revealed an area of pelvic inflammatory disease involving both kidneys in dense adhesions. Cultures indicate chlamydia. Both ureters were almost totally blocked. Dense adhesions were painstakingly taken down. This was done very carefully and requires several hours of surgery. Care was taken not to sever the kidneys or ureters. Intercede adhesion barrier was applied. Postoperatively, the patient was pain free. Discharge Instructions: The patient was discharged home. Diagnosis: Severe pelvic adhesions, chlamydia infection.

Answer 1

As per case study review :

• Reason for Hospitalization is documented
• Pre-Operative Diagnosis is Documented
• Summarized entire hospital duration of the hospital stay
• Diagnostic results documented (CT scan of Kidneys)
• Surgical Procedures and recovered very well
• infection Markers identified chlamydia Infection
• Discharge instructions not documented clearly Ex: Post operative wound care furhter follow up for the problem
• Fail to document Discharge medications list and dosage and frequency