If a physician dictated a discharge summary before the patient was discharged, what is the best course of action?

When a physician dictates a discharge summary before the actual discharge of the patient, it is essential to maintain the accuracy and integrity of the medical record. The best course of action is to request that the physician dictate an addendum to the discharge summary. This approach allows for the inclusion of any relevant details that may arise between the dictation and the patient's actual discharge, ensuring a more comprehensive and accurate account of the patient’s status and care during the hospitalization.

An addendum serves to provide context or modify previously documented information, addressing any discrepancies that may exist due to the timing of the dictation. It ensures that the discharge summary reflects true and complete patient care data, which is crucial for continuity of care and for meeting legal and regulatory standards in health record management.

In contrast, simply noting the date discrepancy or filing the record as complete does not resolve the issue of accuracy in medical documentation. Requiring a new discharge summary may unnecessarily complicate the situation and could lead to redundant documentation. Thus, the best practice is to enhance the existing summary with an addendum, ensuring the record is precise and up to date.