Discharge summary documentation must include

Question

A. a detailed history of the patient.
B. a note from social services or discharge planning.
C. significant findings during hospitalization.
D. correct codes for significant procedures.

Answer 1

C "A detailed history of the patient" is incorrect because some reference to the patient's history
may be found in the discharge summary but not a detailed history. "A note for social services
or discharge planning" is incorrect because the attending physician records the discharge
summary. "Correct codes for significant procedures" is incorrect because codes are usually
recorded on a different form in the record.