• All outside entities providing services. • The summary should be mailed or faxed to the physician, while maintaining the original in the patient/client chart. Notation of the summary being sent to the physician should appear on the form. Transfer Summary A transfer summary for a planned transfer must be completed and sent to the receiving entity prior to or simultaneously with the initiation of patient/client services at the new entity; or within two business days of becoming aware of an unplanned transfer if the patient/client is still receiving care in the healthcare entity at the time when you become aware of the transfer. The content of the transfer summary typically contains the same components as listed below for a discharge summary. Discharge Summary A summary must be completed at discharge and sent to the primary care practitioner or other healthcare professional(s) who will be responsible for providing care and services to the patient/client after discharge from the Agency within five business days of the discharge. The summary includes: • Admission and discharge dates. • Physician responsible for the home health plan of care. • Reason for admission to home health. • Type of services provided and frequency of services. • Laboratory date(s). • Medications the patient/client is on at the time of discharge. • Patient’s/client’s discharge condition. • Patient/client outcomes in meeting the goals in the plan of care. • Patient/client and family post-discharge instructions. If SN, PT, OT, or ST discharge prior to the final agency discharge, a discipline specific discharge should be completed and sent to the ordering physician and/or non-physician practitioner. Documentation that is submitted will be reviewed for thoroughness, completeness, and skill. If it is incorrect, the Agency will contact the staff person to correct it as soon as possible.
