Decision Status: In Progress
Discharge Documents
Do we specify SMD?
Do we specify Role?
So we specify Setting?
The definition of a Discharge Summary should be, by definition, a document at the end of a HOSPITAL stay. It concludes the stay that started with an 'admission', so a discharge is needed. This means it is not a document used after a specialist clinic visit, or after a nurse finishes doing wound care home visits. She does not 'discharge' from the Wound Care service.
Add SMD? - Quebec recently decided that there would be no subject matter domains with their discharge documents. Just one discharge document for all hospital discharges. Northern Health in British Columbia does the same thing, and I think it's encouraged in all of BC. One argument for this is that multiple specialists would see a patient in a hospital, so to claim that the discharge summary, which summarizes the results of all these specialists, has a particular specialty of its own, is misleading. For example, a cardiologist and a nephrologist see a patient, but cardiology is the SMD of the discharge summary. It is also rare for there to be multiple discharge summaries with different specialties. It is more common, after a specialty finishes seeing a patient in the hospital, that they write a progress note. However, we know that each discipline would like to have the option to write a discharge note, because it does happen that someone comes in to see just nephrology or respirology and then they discharge them.
Add Role? - If most physicians write the discharge summary, we do not need to specify the level of training that the physician has, therefore "Attending" is not needed. However, NP's and PA's do write discharge summaries. However, these do roles do not change the content of the discharge summary by much. If there is a nursing discharge summary,
Add Setting? - Using the strict definition of Discharge Summary, they are always from a hospital. LTC would be the exception but they do so few discharges we won't make a concept now
We discussed the HRM committee's interest in having Midwife documents sent to them. We decided that doesn't mean the LOINC code needs to carry the responsibility of identifying midwife-authored documents. So we will not add Midwife as a role.
Decide to include Type: Discharge Summary paired with all SMDs. The Role and Setting will be unspecified.
We will also have a concept of Type Discharge Summary that has no SMD or Role or Setting specified. This will be our preferred document type for discharge summaries. It is the most honest representation of the document since it isn't from one discipline's perspective.
Votes