Writing a Discharge Report on a Patient You Never Treated
A therapist (employee or traveler) has left your practice or organization. After they left, you realize this therapist had 1 or more medical records they did not write a discharge report on. A question I am often asked is can another therapist that is employed by the practice or organization who never treated this patient write the discharge report based on the existing documentation in the medical record?
The answer is
The content here is for members only log in here or sign up.
All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.
This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.
Check Our Past Webinars!
Leave a Reply
Your email address will not be published. Required fields are marked *This site uses Akismet to reduce spam. Learn how your comment data is processed.
Thank you. Follow up question is does a discharge note have to be written? If the treating therapist is gone and you are recommending another therapist does not write it, I assume that means you would recommend that no discharge note be completed?
Thanks
That is not what I am recommending. The article is pointing out possible liability for a therapist. Based on the article, practices and organizations need to ensure documentation is completely timely by the applicable therapist.
Based on your discharge recommendations should the manager of the department write something in the medical record to state the supervising therapist left the organization with incomplete documentation?
I am not making any recommendations for what a practice or organization should do. That would be for them to decide.