Q&A: Documenting the Patient Choice List

Q: Does the choice list given to the patient during discharge planning need to be kept in the permanent medical record?

A: That’s a great question and the answer is it depends on your hospital policy on choice. If your hospital policy on choice says that you must keep the choice list on file, then that should be in the medical record. If you have a hospital policy on choice, you may want to get it out and look and see. What does it say about documenting patient choice? Do you need to list everybody that you sent the referral to and only two accepted? That should be in your choice policy. The use and disclosure of HIPAA should be used as a basis for the answer to that question. Medicare will not tell you how to do it; they tell you, you must do it. It’s up to what your policy says.

This question was adapted from the HCPro webcast "Discharge Planning: Realignment of Standards and Workflow" featuring Jackie Birmingham, RN, BSN, MS, CMAC, and Janet L. Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, C-ASWCM, ACSW.

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