Where is the discharge diagnosis usually recorded?

The discharge diagnosis is typically recorded on the face sheet or discharge summary, as this document provides a comprehensive overview of the patient's hospitalization, including key clinical information, the reason for admission, treatments received, and the patient's condition upon discharge. The face sheet often includes essential patient information and serves as a readily accessible summary for healthcare providers, ensuring continuity of care.

This documentation is crucial for proper coding, as it not only provides a summary of the patient's stay but also establishes a clear rationale for the care provided, which is important for future medical records, billing, and quality control. Other options, while they may contain relevant information, do not serve as the primary documentation for discharge diagnoses. For instance, the operative report details surgical procedures performed, the medication list keeps track of prescribed drugs, and the billing statement focuses on the financial aspect of care rather than clinical details.