TJC & CMS News Blog
Information for

Although it is not a part of the formal agenda, most TJC surveys typically include a review of a sample of closed records in addition to the open record review that takes place during tracer activities. There are specific elements that surveyors are evaluating when they review closed records so let’s take a look at those:


Timeliness of Discharge Summaries

Surveyors are evaluating whether discharge summaries have been completed within the timeframe required by TJC and organizational policy (whichever is more stringent.) The TJC timeframe is a maximum of 30 days post discharge for completion of the discharge summary. However, many organizations have established shorter timeframes for completion of discharge summaries. As always, TJC will hold you to your own policy.

Survey Readiness Strategy: Track completion of discharge summaries on an ongoing basis as part of your PI program; address timeliness issues as needed.


Content of Discharge Summaries

Remember, the content of the discharge summary is defined by TJC standards. For psychiatric hospitals, discharge summaries must include the following (RC.02.04.01 EP 3):

  • Reason for hospitalization
  • Procedures performed
  • Care, treatment, services provided
  • Patient’s condition and disposition at time of discharge
  • Information provided to patient and family
  • Provisions for follow-up care

The requirements for BH organizations are the same (with minor wording differences.) See RC.02.04.01 EP 3.

Survey Readiness Strategy: Review your format for discharge summaries and make sure it covers all the required elements.


Discharge Instructions

Written discharge instructions are required by both the Hospital and Behavioral Health standards; Hospital: PC.04.01.05 EP 8; BH: CTS.06.02.03 EP 9. Discharge instructions must be written in a manner that the patient/client and family can understand. Discharge instructions should include information about continuing care services that are being recommended.

In addition, one of the most important items that must be included in discharge instructions is information on medications that the individual should take after discharge. These medication instructions must be written in plain language (not medical terminology). Thus, terms such as “BID” should not be used but, rather, should be written as “two times per day.” Many psychiatric hospitals have been cited on this issue.

Also, be aware that the National Patient Safety Goal on medication reconciliation (NPSG.03.06.01 EP 4, 5) in both the Hospital and BH manuals requires that the patient/client and family be provided written information on medications to be taken after discharge and that the individual be educated on the importance of managing their medications.

Survey Readiness Strategy: Audit your closed records to ensure that discharge instructions are written appropriately and that there is documentation of education for the patient/client and family.


Discharge Information Shared with Other Providers

When a patient/client is transferred or discharged, TJC requires that pertinent information be shared with other providers who will be treating the individual. For hospitals, this information must include (PC.04.02.01 EP 1):

  • Reason for patient’s discharge or transfer
  • Patient’s’ physical and psychosocial status
  • Summary of care, treatment, services provided
  • Patient’s progress toward goals
  • List of community resource or referrals made or provided to the patient

The requirements for BH organizations are the same (with minor wording differences.) See CTS.06.02.05 EP 1, 2.

In addition, psychiatric hospitals must also comply with the Hospital Based Inpatient Psychiatric Services (HBIPS) measure that requires that a post discharge continuing care plan be created and transmitted to the next level of care provider upon discharge.

Survey Readiness Strategy: Psychiatric hospitals keep close tabs on compliance with this requirement since it’s an HBIPS measure. BH organizations should conduct an audit to evaluate their compliance with sending discharge information to continuing care providers.

In summary, make sure your Joint Commission continuous readiness process includes attention to documentation at time of discharge. Include review of closed records as part of your ongoing medical record review process. Identify gaps in compliance and take action on those before they wind up in your survey report!