Discharge summary format for insurance claims: what every summary must include
The discharge summary is the first page a claim reviewer reads. These are the fields it must have, and the mistakes that cause queries.
A claim reviewer often decides whether to query a file from the discharge summary alone. A complete, consistent summary makes the rest of the file easy to approve.
Fields every summary needs
- Patient name, age, gender and hospital number, exactly as on the ID and claim form.
- Dates and times of admission and discharge.
- Presenting complaints and the reason admission was needed.
- Relevant past history, written as it is.
- Findings on examination and key investigation results.
- Final diagnosis, with ICD-10 code where your hospital uses them.
- Treatment given, with procedures and dates.
- Condition at discharge and advice, including medicines and follow-up.
- Treating doctor's name, signature and registration number.
Common mistakes
- Dates that differ from the nursing chart or the bill.
- A diagnosis that does not match the investigations in the file.
- A template copied from another patient with details left unchanged.
- No signature, or a signature with no name and registration number.
Make it a habit
Use one format for the whole hospital, and check each summary against the file before discharge. Ekline Claims does that check automatically and flags any mismatch with the page number.
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