CMS is proposing a new standard for discharge or transfer summary content that would be sent to the receiving facility or practitioner.
 
This must include at a minimum:
  • Demographic information, including name, sex, date of birth, race, ethnicity and preferred language;
  • Contact information for the physician responsible for the home health plan of care;
  • Advance directive, if applicable;
  • Course of illness/treatment;
  • Procedures;
  • Diagnoses;
  • Laboratory tests and the results of pertinent laboratory and other diagnostic testing;
  • Consultation results;
  • Functional status assessment;
  • Psychosocial assessment, including cognitive status;
  • Social supports;
  • Behavioral health issues;
  • Reconciliation of all discharge medications;
  • All known allergies, including medication allergies;
  • Immunizations;
  • Smoking status;
  • Vital signs;
  • Unique device identifiers for a patient’s implantable devices, if any;
  • Recommendations, instructions or precautions for ongoing care, as appropriate;
  • Patient’s goals and treatment preferences; and
  • The current plan of care, including goals, instructions and the latest doctors’ orders.
Many of these medical information elements may not be applicable to the patient. Therefore, CMS expects agencies to include this information with a “N/A” next to each data element that doesn’t apply.