An accurate discharge summary is crucial for the healthcare unit. Discharge summaries can be prepared meticulously with the help of medical transcription professionals.

1. Significance of Accurate Discharge Summary and Error-free EHR
An accurate discharge summary is crucial for the healthcare unit. Discharge summaries can be prepared
meticulously with the help of medical transcription professionals
MEDICAL TRANSCRIPTION SERVICE COMPANY
8596 E. 101st Street, Suite H
Tulsa, OK 74133
Phone : 1-800-670-2809

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Information is an important aspect of the healthcare process because it is necessary to
deliver quality services. It is also required to meet statutory standards, manage risks
and ensure profitability. Medical transcription services play an important part in
providing a well-organized medical record containing the accurate transcription of all
dictated material. Patient information collected before, during and after the treatment
and care include patient demographics, presenting complaints, symptoms, existing
conditions, medications, results of various tests and lab reports, procedures, information
regarding insurance coverage and so on. Medical transcription may be required for
various types of medical reports, one of which is the discharge summary.
Components in a Discharge Summary
 Patient identification
 Principal diagnosis
 Surgical or other significant procedures
 History of present illness
 Hospital course
 Patient’s condition
 Findings and diagnostics
 Treatment and procedure
 Consultations
 Complications
 Condition of the patient at the time of discharge
 Discharge plans and instructions
 Disposition
 Instructions or recommendations
 Medications
 Orders for post–discharge diagnostics test
 Referral appointments
 Physician’s signature with date and time
 Document creation date and time
Significance of the Discharge Summary
A discharge summary is an important document that contains vital information such as
admission and discharge diagnoses, a review of the patient’s medical history and the
physician’s findings on physical examination, procedures/surgeries performed, lab test
reports, important findings, details of the patient’s hospital course, medications
prescribed when being discharged, discharge plan and so on. An accurate and

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comprehensive discharge summary is crucial for the healthcare unit and with reliable
medical transcription, discharge summaries can be prepared meticulously.
Accurate discharge summary helps in
 Protecting claims
 Preventing readmission of patients
 Improving patient care
 Helps doctors in further investigation or can be used as a referral
Discharge summaries are essential for a patient’s continued healthcare and an important
document in his or her medical history. These summaries are the key reports for
substantiating the medical necessity at the time of admission and coding diagnosis. With
a detailed discharge summary auditors will be able to see the reason why the patient
was admitted, the treatment provided during the stay, and the recommendations given
at the time of discharge of the patient.
Discharge summaries are also referred to as handoff documents that are given from the
hospitals to outpatient environment and this helps the post discharge healthcare
provider to access all the information and know the medical history of the patient.
A discharge summary includes outcome of the hospitalization, disposition of care,
medications, adverse reactions and complications, healthcare related allergies, and final
diagnosis. According to a research by the Yale University School of Medicine, preparing a
detailed discharge summary and quickly making it available to the patient’s doctor
improved patient outcome after hospital stay and reduced the chances of readmission
within 30 days.
A Vital Element for Coding and Billing
Discharge summaries reflect clinical information and the physicians can get involved in
the diagnosis, identify which conditions were considered and which conditions were ruled
out. Any decisions made by the healthcare providers that impact the stay and qualify as
a principal or secondary diagnosis should be mentioned in the discharge summary.
Sometimes physicians may “copy” and “paste” data from previous admission. It is
important to mention every minor detail accurately in the discharge summaries to avoid
any legal issues. A discharge summary is said to be complete once the physician
completes and signs it. Accuracy of this document is very important with regard to
medical coding and billing for physician/hospital reimbursement.
In a hospital there will be many inpatients, and preparing discharge summaries for all
these patients can be tedious and time consuming. There is a high chance of making

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wrong entries as well, especially if the staffs are overworked. This is where outsourced
transcription services can prove helpful. Physicians can dictate the details and the
transcription service provider will prepare an accurate and reliable discharge summary
for each patient.
EHR and Medical transcription
Today with EHR, hospitals can efficiently organize and store error-free patient data. But
successful implementation has become a roadblock to many hospitals and clinics as the
physicians struggle with capturing the complexities of their patients’ health conditions
and this reduces their productivity. To save time, many physicians simply copy and paste
data from previous admissions, and this leads to inaccurate documentation.
Hospitals can resolve this situation with the help of outsourced medical transcription.
Professional transcriptionists can assist in two ways.
 Physicians who use EHR with voice recognition can rely on transcriptionists who
work more in the capacity of medical editors and ensure that the transcripts from
the voice recognition software are accurate, and make necessary modifications if
needed.
 Physicians can opt for EHR integrated medical transcription services. They can
dictate the details into a digital recorder or telephone and send the audio files to
the transcription service provider. The audio files are transcribed into accurate
patient narrative and then the required information is uploaded into the EHR
fields using HL7 interface. The main benefit of this combined method is that
physicians can retain their workflow and continue to dictate into automated
system. This increases the productivity of physicians and other healthcare
providers.
Hospitals can record accurate and precise patient’s data in their EHR systems with the
help of medical transcription services. Outsourcing the transcription requirements is a
better option mainly because medical transcription is a specialized process that requires
considerable investment, professionalism on the part of the transcriptionists and
undivided attention – requirements which may be difficult to meet with in-house
resources. Partnering with a good medical transcription company can prove
supportive, ensuring smooth and efficient workflow and improved productivity.