The discharge summary, a key document in acute care, must be completed by whom?

Study for the RHIT Domain 1 Test with flashcards and multiple choice questions. Each question includes hints and explanations. Prepare effectively for your exam!

The discharge summary is a crucial document in acute care as it encapsulates the patient's hospital stay, treatment events, and discharge instructions. The responsibility for completing this document lies with the attending physician. This is because the attending physician has the most comprehensive understanding of the patient's condition, treatment plan, and outcome during the hospitalization. They are also tasked with ensuring that all the necessary information—such as diagnoses, procedures performed, medications, and follow-up care—is accurately documented for both the patient and any subsequent healthcare providers.

The discharge summary serves as an essential communication tool that facilitates continuity of care and provides critical information for the patient’s ongoing treatment. Given the responsibility and authority of the attending physician in a patient's care, this role is proper for finalizing such an important summary. Other professionals, such as nurses and consultants, may contribute information during the patient’s stay but would not be tasked with officially completing the discharge summary. Similarly, medical coders use the discharge summary for coding and billing purposes but do not create or finalize the document itself.

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