American Health Information Management Association (AHIMA) Certification Practice Exam

What is the primary function of a discharge summary in healthcare documentation?

1. Provide a microscopic description of excised tissue.

2. Detail patient history and conditions during hospital stay.

3. Summarize the patient's illness and treatment response at discharge.

4. Document incidents and accidents occurring in the hospital.

The correct answer is: Summarize the patient's illness and treatment response at discharge.

The primary function of a discharge summary in healthcare documentation is to summarize the patient's illness and treatment response at discharge. This document plays a crucial role in providing a concise overview of the patient's hospitalization, detailing the key findings, the care provided, and the patient's condition at the time of discharge. It includes critical information for continuity of care, ensuring that follow-up healthcare providers have a comprehensive understanding of the patient's treatment course, any complications that arose, and recommendations for ongoing care. This summary is essential for facilitating communication between healthcare providers and the patient and ensuring that any post-discharge plans, such as medication management and follow-up appointments, are clearly outlined. It provides a snapshot that allows for efficient and effective care transition, which is vital in reducing readmission rates and enhancing patient outcomes.