Discharge summary is among the four types of reports that comprise the core of medical transcription work and is required whenever a patient is discharged from the hospital. This report is critical for further consultation and promoting patient safety while they transfer from care settings. If a patient dies instead of being discharged, the discharge summary becomes the death summary. Accurate death reports are crucial to receive social security benefits and reimbursements.
The accuracy of death summary is very important since the relatives of the patient who had died in the hospital can sue the hospital for wrongful death/negligence if they find the death report is incomplete and comprised of critical errors. According to a news report, a hospital had to pay more than $9 million to a family in wrongful death lawsuit. The victim had a history of bleeding problem and there was no documentation regarding what blood would be needed or when. The correctness of death summary is critical for patients too as the Social Security Administration (SSA) creates a set of death records by collecting death reports from multiple sources (family members, state vital records agencies) and ensures the accuracy of those documents before paying federally-funded benefits.
In order to generate accurate and complete reports, the medical transcriptionist should understand how death summary differs from discharge summary. Even though death summary comprises a subset of the typical discharge summary, it is different discharge summary in the following ways:
- ‘Discharge Date’ will be changed to ‘Date Expired’ or ‘Date of Death’
- Discharge Diagnoses will become Final Diagnoses
- Cause of Death may be dictated as an explicit heading depending on whether the cause is known or not during the dictation of death summary (sometimes, a pending surgical pathology report or autopsy record is needed to confirm the cause of death)
The death summary should also include the information on whether the patient’s family had already agreed to an autopsy and whether there is a living will of patient that calls for no aggressive therapy. In case, the patient does not have a living will, the family or next kin of the patient can make this decision and this information should be also included in the death summary. Usually, the death summary would comprise only Final Diagnoses and Hospital Course sections.
The dictator may sometimes give a narrative description with no headings and it is the job medical transcriptionists to arrange the information under proper headings. Hospitals can seeking the help of a medical transcription company to transcribe death summaries along with discharge summaries should take time to provide good documentation on expectations so as to ensure a smooth flow of information to generate good documentation.