Performance Measurement Network

Question: When there is a discharge summary and an addendum present in the medical record, which should be used?

This is follow up to a prior question: "";.

The patient's discharge was postponed and an addendum written two days later than the discharge summary. The addendum only addresses the last two days of hospitalization. Can both documents be used, or only the addendum since it is dated after the discharge summary?

Answer:

For 4/1/10+ discharges: An addendum to a discharge summary identifiable as an addendum does not count as a separate discharge summary. Therefore, in the type of case you describe here, information from both your discharge summary and the addendum (both completed within 30 days after discharge) get factored into abstraction.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK, Antithrombotic Therapy Prescribed at Discharge,
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