Patient Summary Information (AKA Clinical Summary)

Introduction

Mea SEO serviceningful Use dictates that a patient must be provided with a summary of care within 3 business days of the patient being seen. Clients may use a variety of different tools as clinical summaries. V10 structured notes, v11 note outputs, the Allscripts-delivered Clinical Exchange document (CED), or the Allscripts-delivered Rich Text Format(RTF) document can all be tied into the reminder feature on the schedule and be tracked by AHS Meaningful Use reports. Please note that at this time (9/2011), the RTF document cannot be sent to the patient portal. This funcitonality is expected to be incorporated into v11.2.2.

For reporting, the application reports on the percentage of all arrived appointments where the Clinical Summary Icon has been set to provided.

It is important to note that clinical summaries can only be provided for patients in an ARRIVED status; therefore even once the setup below is complete, the checkbox to provide a clinical summary will be grayed out if the patient has not been arrived.

Requirements for Patient Summaries

The Meaningful Use Rules define a Clinical Summary as an after-visit summary that provides a patient with relevant and actionable information and instructions containing, but not limited to, the following:

The patient name
The provider’s office contact information
The date and location of visit
An updated medication list and summary of current medications
Updated vitals
The reason or reasons for visit
Procedures and other instructions based on clinical discussions that took place during the office visit
Any updates to a problem list
Immunizations or medications administered during visit
A summary of topics covered or considered during visit
The time and location of next appointment or testing if scheduled or a recommended appointment time if not scheduled
A list of other appointments and testing patient needs to schedule with contact information
Recommended patient decision aids
Laboratory and other diagnostic test orders
Test or laboratory results (if received before 24 hours after visit)
Symptoms

Creating v11 Note Output Clinical Summaries

If an organization decides to make the v11 Note Output their Clinical Summary, the "Is Clinical Summary" checkbox in the General Properties II section of the Document Dictionary must be checked for the document type linked to the Clinical Summary Note Output.

NOTE: This is enabled for the following Manifestations: NOTEFORM, HTML, and RTFXML (cannot create new Document Types using RTFXML).

Related Allscripts Preferences and Security Requirements for Clinical Summary

Preferences

Suggested preference settings:

EnableCSOnScheduleDaily = Y; Also check the box "User can Override"
- Enables users to personalize their Daily to include the Clinical Summary (CS) column.
EnableCSOnScheduleProvider = Y; Also check the box "User can Override"
- Enables users to personalize their Provider Schedules to include the Clinical Summary (CS)column.

Set these preferences according to organizational requirements:

EncounterSummaryAlwaysProvideClinicalSummary
- Set to Y if you want the Provide Clinical Summary check box on the Encounter Summary to be selected by default. The provider can clear the check box if they do not want to provide a clinical summary for that encounter.
- Set to N if you want, by default, the Provide Clinical Summary check box to be unchecked. The provider can select the check box to provide a clinical summary for that encounter.
- Set to Disable if you want the Provide Clinical Summary check box to be unchecked and disabled. Providers are unable to select the check box.
AllowClinicalSummaryWhenNoteUnFinal
- Determines whether an unfinalized note can be used as a Clinical Summary.
- Set to Y if you want providers to be able to generate the Clinical Summary before the note is finalized.
- Set to N if you do not want providers to be able to generate the Clinical Summary before the note is finalized.

Security

Chart View and Chart Print security is required in order to provider the Clinical Summary to patients.

Additional Setup

Set the Auto-Print Defaults for the Clinical Summary - CED auto-print defaults are set in the same place as all other Auto-print defaults. The Type to choose is Clinical Exachange Document.
- NOTE: Auto-print defaults for v10 and v11 Clinical Summary notes are set under Auto-Print Defaults, where the type=Notes.
Ensure the staff is entering the patient's preference for receiving their clinical summaries into the Patient Profile. Possible options include:
- Print - the application prints the Clinical Summary using the auto-print defaults set up in TWAdmin. Auto-print defaults are not required, but can be used to automate as with printing any document. If auto-print defaults are not defined, the application displays the Print dialog so you can choose the printer.
- Save to File - the application saves the Clinical Summary to any drive that you specify(typically a Flash/USB drive that the patient has provided). You can save the Clinical Summary for a CED, or v10/v11 Note to file as a PDF.
- Patient Portal - the application sends the Clinical Summary to the portal (only for v10 Notes and CEDs).
- Declined - the application does not generate the Clinical Summary and the Provider or Daily Schedule displays N/A for the appointment. The clinician receives credit for attempting to provide the Clinical Summary.
- Patient Portal & Print - the application prints the Clinical Summary and also sends it to the portal.
  - NOTE: If a v10 or v11 Note is linked to the encounter, that document is printed, but the CED is sent to Portal. The one exception is if the portal is Intuit Health and the Note is v10 Note. In that case the application can send the v10 Note to Portal, as well as print for the patient.

NOTE: If the patient does not have a preference set, the application behaves as if the preference were Print.

Frequently Asked Questions

Can you Fax a Clinical Summary from Enterprise EHR?

You cannot fax the CED Clinical Summary from the EHR; however you can fax any v10 or v11 document that is used as a clinical summary.

Additional Resources

v11.2 ABDR - Encounter_Clinical_Summary_Enhancement_V11 2_EEHR1.pdf