Avoiding a Citation for a Discharge Summary

By Lynn A. Milligan, MSN/ED, RN, DNS-CT, RAC-CT - February 26, 2019

The State Operations Manual (SOM) defines an anticipated discharge as “a discharge that is planned and not due to the resident’s death or an emergency (e.g., hospitalization for an acute condition or emergency evacuation).” For every discharge that meets this definition of anticipated, whether it be to another healthcare facility or to the resident’s home, the discharging facility is required to provide a discharge summary. With its primary purpose being to ensure that care is safely coordinated from one setting to another, the discharge summary must inform the continuing care providers of the course of treatment provided by the discharging facility. This document should be detailed and include an accurate description of the resident’s current status along with current individualized care instructions.

In order to avoid a citation for §483.21(c)(2) F661 (Discharge Summary), the discharging facility must include at least the following in the discharge summary: