Any documentation regarding patient care should be:
- dated and signed with designation
- legible
- sufficiently detailed to enable continuity of care, education and research
In addition to general medical record documentation, it is required that a discharge summary (MR4) is completed for all patients staying in the hospital overnight or longer.
The details required include:
- co-morbidities (conditions present on admission and treated. These conditions resulted in a change to the patient's treatment / care / length of stay)
- complications (conditions which arose during the admission and affected the patient’s treatment / care / length of stay)
- discharge medication
- principal diagnosis (the condition which after investigation was found to be the cause for the admission)
- procedures (surgical / non-operative / diagnostic / therapeutic procedures which require anaesthesia / sedation / injected contrast)
- summary of care.
A discharge summary should be completed within 48 hours and a relevant copy will be sent out to the General Practitioner by Health Information Services (Medical Records).
There are two types of operation records for those undertaking surgical procedures:
- MR23AA Operation Record for all day and overnight surgical patients
- MR17 Day Surgery Record – still used at Epworth Eastern for day patients only
Details that are required to be documented in these forms include:
- anaesthetist
- assistant
- diagnosis
- MBS number(s)
- patient details
- post-operative/discharge instructions and orders
- procedure(s)
Doctors who require copies of the completed MR4 Discharge Summary for their own records, or for their patients referring doctor, can indicate this using the 'tick box system' in the top left hand corner of the form.
The documentation recorded in the medical record, discharge summary, operations records, progress notes and other clinical notes is integral to classifying the admission into the correct Diagnostic Related Group (DRG). The DRG is used to indicate resource consumption, helps demonstrate the acuity and complexity of the episode, and its accuracy is important to ensure correct reimbursement from the health funds. Guidelines on the documentation of co-morbidities/complications to assist with DRG allocation are provided as an appendix in this Handbook.
If you have any questions on completion of discharge summaries, documentation or coding please contact your site coding educator or health information manager.