Elements Needed to Meet CMS Regulations Essay Assignment Paper

Posted on March 28, 2023

Question

Evaluate the following discharge summary compared to CMS regulations and recommend additional element or elements needed to meet CMS regulations.

Discharge Summary

Discharge Date: 8/1/2017

Pertinent History: The patient is a 34-year-old female admitted through the ER on 7/24/2017 with severe, stabbing, low-back pain and inability to urinate. The patient has a long history of pelvic inflammatory disease, with three surgical episodes to remove implants. CT scan revealed a mass in the area of the kidneys.

Hospital Course: The patient was admitted, prepped, and taken to surgery. Exploratory laparotomy revealed an area of pelvic inflammatory disease involving both kidneys in dense adhesions. Cultures indicate chlamydia. Both ureters were almost totally blocked. Dense adhesions were painstakingly taken down. This was done very carefully and requires several hours of surgery. Care was taken not to sever the kidneys or ureters. Intercede adhesion barrier was applied.

Postoperatively, the patient was pain-free.

Discharge Instructions: The patient was discharged home.

Diagnosis: Severe pelvic adhesions, chlamydia infection.

ORDER A PLAGIARISM-FREE PAPER HERE

Step 1/2
The provided discharge summary lacks several elements that are necessary to meet CMS regulations. Here are some additional elements that should be included in the discharge summary,
Explanation:
  • Discharge status:
The discharge summary should state the patient’s discharge status which could be one of the following,
  1. Discharged to home
  2. Transferred to another facility
  3. Discharged against medical advice.
  4. Expired.
  • Follow up care:
The discharge summary should include instructions for follow up care, including any appointments or tests that the patient needs to schedule.
  • Medications:
The discharge summary should list all medications the patient is taking, including the name, dosage and frequency of each medication.
Step 2/2
Some of the other points also include,
  • Results of diagnostic tests
  • Functional status
  • Discharge plan
  • Prognosis
Explanation:
  • Results of diagnostic tests:
If any diagnostic tests were performed during the hospital stay, the discharge summary should include the results.
  • Functional status:
The discharge summary should include information on the patient’s functional status at the time of discharge such as ability to perform activities of daily living.
  • Discharge plan:
The discharge summary should describe the plan for the patient’s ongoing care including any referrals to specialists or home health services.
  • Prognosis:
The discharge summary should include a statement about the patient’s prognosis including any potential complications or outcomes.
Final answer
Some additional elements that should be included in the discharge summary,
  • Discharge status
  • Follow up care
  • Medications
  • Results of diagnostic tests
  • Functional status
  • Discharge plan
  • Prognosis
  • Elements Needed to Meet CMS Regulations Essay Assignment Paper

Leave a Reply

Your email address will not be published. Required fields are marked *