Medical Summary Medical Summary
The following topics are discussed on this page. Use the links to jump to the desired subject:
- To view details regarding a Medical Summary
- To perform a Clinical Reconciliation
- To create a new Medical Summary
- To view details regarding an Generated Medical Summary
- To print the Medical Summary
- To preview a Generated Medical Summary
The patient's current patient portal registration status is displayed at the top of the page. To print the letter for the patient that includes the PIN so they can completed Patient Portal registration, click the Generate Portal PIN button. A letter is displayed that contains a PIN code. Print this letter and give it to the patient to complete the registration.
Setup Note: If you don't see (or have access to) the Generate Portal PIN button, make sure that you have user security to the button (User Administration > Master Files > User Roles) AND are set up as a clinical user in the InteliChart Practice Portal.
The Medical Summary page is used to view, create, and upload/import, and export electronically generated medical summaries for the patient. From this tab, you can view, upload, download, and prepare and generate the Medical Summary. In addition, from this page, you can perform Clinical Reconciliation between imported documents and the patient's current record for Medications, Medication Allergies, and Problems.
Some of the functionality now located on the Medical Summary page was previously located in Reports > Discharge Docs > Electronic Health Record and has now been moved to it's own tab in the Patient Chart.
The Medical Summary page is divided into three sections:
In addition, you can view the list by using the filters at the top of the page: View, Start Date and End Date. Since the default view is for the current visit, use the View field to select other options: Recent Visits, Date Range, or All Visits. If you select Date Range, use the Start Date and End Date fields to specify the time period to view. If you select Selected Visit or Date Range, use the Start Date and End Date fields to specify the time period to view. If you select Recent Visits, enter the number of visits in the adjacent field. Then, select the types of visits to display in the third field. To save your selections in these fields so that they are the same when you return to this page subsequent time, go to Actions > Save Filter Settings.
The External Medical Summaries documents have been received from an external location and have been uploaded to the Patient Chart. The items are listed with columns for Authored Date, Document Type, Author Organization, Action By, and Action On. And, to the right of each item is a series of action buttons to perform actions on the documents. These buttons are Show Details, Clinical Medication Reconciliation, Preview, and Export, as well as the option to Upload a new document.
From the Medical Summary, you can upload a document from a file that a patient may bring to you on a flash drive or CD. To begin the upload, click the Upload button. The Upload box is displayed.
To view the details for a specific Medical Summary, such as Visit #, Source, and File Description, click the Show Medical Summary Details button.
The Clinical Reconciliation feature is used to import pieces of data, specifically, Medications, Allergies, and Problems from external documents to the patient's medical record (Patient Chart). These documents can be received from an import or a secure message.
Once the Medication Reconciliation page is displayed, you will see two columns of information. The patient's current Patient Chart information is displayed in the column on the left. And, the imported information is displayed in the right column. In addition to the two columns, there are 3 horizontal sections displaying the data: Medications (Home Medications), Medication Allergies, and Problems.
The current information defaults to checked, this is the information that will remain in the Patient Record after the reconciliation.
Begin by checking items in the imported information that you wish to keep/import into the Patient Chart.
Then, if desired, uncheck items from the Current record that you wish to discontinue from the patient's record.
Then, click Verify Reconciliation. The Verify Reconciliation window is displayed. This window has 3 tabs for each of the 3 sections and lists the current information that will be reflected in the Patient Chart.
Review each tab and confirm the information is correct.
Then, click Submit. The changes to the Patient Chart have been imported/updated. Note: If items are being added from the external document, you may need to verify and/or edit items as they are being imported, i.e. problems, SNOMED codes, medication details, etc. The appropriate dialog boxes are displayed highlighting the required information. Complete the required fields and click Save.
Click Back to return to the Medical Summary page.
To view a Medical Summary, click the Preview Medical Summary button located to the right of the document details. The document opens in a new tab. The Table of Contents are displayed to the left of the document. Click on a topic/category to go directly to that section. To print this document, use the browser Print function, i.e. File > Print.
To export a Medical Summary, locate the desired document in the External Medical Summaries section and click the Export Medical Summary icon located to the right of the item. The Export window is displayed.
Enter the recipient secure email address (or search if recipient has been used previously) in the To field.
In the Subject line, enter the Subject of the message.
In the Communication field, enter the text of the message.
Review and apply the appropriate status of the message in the Status field.
Click Send.
(For more information regarding Secure Messaging, see Patient Communications.
The Generated Medical Summaries documents have been generated from the Patient Chart information in the Centriq applications. The items are listed with columns for Authored Date, Visit #, Document Type, Action By, and Action On. And, to the right of each item is a series of action buttons to perform actions on the documents. These buttons are Show Details, Preview, and Export, as well as the option to Prepare a new document.
To create a new Medical Summary, click the Prepare Document button. A new view is displayed.
In the Patient Summary Documentation field, select the type of document you are creating.
Continuity of Care Document:
Clinical Summary: This is typically the type of document you would print and give to the patient. Also, the type of document used to send to the Healthland Patient Portal (powered by InteliChart).
Export to Third Party: This is typically used when sending/exchanging the document to a third party.
Referral Summary:
This document type is typically used when referring to another
provider. These documents are usually sent to another provider
using secure messaging. (For additional information, see Patient
Communications.)
Selecting the type of Patient Summary displays the sections
included in the document in the Table of Contents. For the type of
document that you selected, there are default items selected/included
in the document. Deselect/Select the items you wish to include/exclude
in the summary. (Checked items are included.) You can choose to remove
categories, by de-selecting/selecting in the green Table of Contents
section. Or, you can elect to deselect individual pieces of information
in the Detail section on the right.
Home Medications: In
the Home Medications section, you can select to show all the medications
or to show only active medications. In the
Filter field, use the drop-down list to select Show
Active Only (default) or Show
All.
(Optional) Add Care Team Members: In the Care Team Members section, you can maintain the patient's list of care team members.
Click Add Care Member. The Add Care Team Member box is displayed.
In the Type field, select the type of care member: Staff or non-Staff.
In the Search field, begin typing the name of the care member, then click the name to select it. If you selected Non-Staff, you can add a new non-staff member by clicking the Add New button. Then, select the Relationship to the patient for the non-staff member.
Once finished, click Save and Close to go back to the Table of Contents view or click Save and Add More to add more care members to the patient's record.
(Optional) Add Referrals: In the Referral Information section, you can add referral information to the list.
Click Add Referral. The Add Referral box is displayed.
In the Sending Provider field, enter the name of the physician who sent the patient to the receiving provider. Click to select from the list.
In the Office Contact field, enter the name and phone number information of the provider sending the referral.
In the Receiving Provider field, enter the name of the provider receiving the referral. Click to select from the list. If the provider is not listed, click the Add New button to add it.
In the Referral Reason field, enter the reason for the referral.
In the Scheduled Date, enter the date the receiving provider is scheduled to see the patient.
Once finished, click Save and Close to go back to the
Table of Contents view or click Save
and Add More to add more referrals to the patient's record.
Click Generate to create
the electronic summary. Once created, the document appears on the
Medical Summary page in the Generated Medical Summaries section. Or,
you can click Generate and Export.
(Note: If required fields are missing, e.g. the Encounter Diagnosis,
you will be prompted to enter the required information.) For details
on selecting this option, go to To
export a Medical Summary. Or, click Save
Draft to save this summary without generating. Drafts appear
on the main page in the Draft section.
Click Back to go back to the Medical Summary page.
To view the details for a specific Medical Summary, such as Date, Type, Action on the document, and Action By information, click the Show Medical Summary Details button. The Details section displays actions on the document and the type of action. To view details on each action, click the Show Details button located to the right of the action details. The Export Type, Requested On, Received On, Reason, Notes, and Encryption information are displayed.
To view a Medical Summary, click the Preview Medical Summary button located to the right of the document details. The document opens in a new tab. The Table of Contents are displayed to the left of the document. Click on a topic/category to go directly to that section. To print this document, click the Print button located next to the document in the Generated Medical Summaries section.
To comply with Meaningful Use Core Measure #12: Summary of Care, you are required to print a copy of the Medical Summary and provide it to the patient. To print a copy for the patient, click the Printer button located to the right of the document. A Print box is displayed. The Printed Copy Provided to Patient check box defaults to checked. This activated check box increments the Numerator 1 for the measure calculation. Then, click Save to print the Summary document.
To export a Generated Medical Summary, locate the desired document in the Generated Medical Summaries section and click the Export Medical Summary icon located to the right of the item. The Export window is displayed.
Enter the recipient secure email address (or search if recipient has been used previously) in the To field.
In the Subject line, enter the Subject of the message.
In the Communication field, enter the text of the message.
Review and apply the appropriate status of the message in the Status field.
Click Send.
(For more information regarding Secure Messaging, see Patient Communications.
The Medical Summary that is generated is created in a Consolidated-Clinical Document Architecture (C-CDA or CCDA)to comply with Meaningful Use requirements. The document contains specified clinical components. The components of the C-CDA document are listed below:
Patient Demographics |
Elements: Displays Patient Name, Patient Address, Phone, Sex, Date of Birth, Race, Ethnicity, and Language. Included in Types:
Data Entered in: Financial > Patient Registration > Registration > Edit MPI window. |
Smoking Status |
Elements: Smoking Status, Start Year, and Assessment Date/Time Included in Types:
Data Entered in: Patient Chart > Admission Assessment (or Assessment) > Substance Abuse > Smoking History. |
Problems |
Elements: Problem (SNOMED code), Occurred Date, and Resolved Date Included in Types:
Data Entered in: Medical History > Problems > Add Problem. Note: Only Active problems (those with a chronicity other than Inactive) are displayed. |
Assessment and Plan (Goals) |
Elements: Start Date, Goal, Instructions, and Status Included in Types:
Data Entered in: Medical History > Problems > Add Goal |
Impairments |
Elements: Condition and Condition Status Included in Types:
Data Entered in: Medical History > Problems > Add Impairment |
Home Medications |
Elements: Medications, Strength, Dosage, Route, Frequency, and Start Date Included in Types:
Data Entered in: Medical History > Home Medications > Add Home Medication |
Medication Allergies |
Elements: Allergen, Reaction, and Status Included in Types:
Data Entered in: Medical History > Allergies > Add Allergy. Note: Only active allergies linked to RXNorm codes are displayed. No Free-text or Environmental allergies are displayed in the document. |
Lab Results |
Elements: Description, Value, Unit, Flag, Normal Range, and Date/Time Included in Types:
Data
Entered in: Laboratory > Results > Enter Results |
Vitals |
Elements: Description, Result, and Charted Date/Time Included in Types:
Data Entered in: Patient Chart > Vitals > Add Vitals |
Procedures
|
Elements: Procedure, Frequency, and Last Procedure Date Included in Types:
Data
Entered in: CPOE > Department Orders. Note:
Document includes all completed orders that have a department
type of Diag Procedure, Isolation, Radiology, Respiratory, Surg
Proc, and Others, which is identified in Master Files > Department
> Order Type. |
Care Team Members
|
Elements: Name, Address, Phone, and Association Included in Types:
Data Entered in: Admitting Provider assigned during Patient Registration, Attending Provider assigned during Patient Registration, Ordering Providers are assigned during CPOE, Supervising Provider, if available, is assigned in PR > Master Files > Medical Staff > Staff > Require Supervisor check box > Supervisor. Nurses/Providers are assigned in Hospital > Assign Staff OR Clinic > Clinician Work Center > Add Physician OR ED > Tracking Board (lower right grey square). Also, Care Team Members can be assigned on the Medical Summary page during the Prepare Document process. |
Provider Information |
Elements: Name, Work Address, Work Phone, and Primary Contact Included in Types:
Data Entered in: Attending Provider assigned during Patient Registration |
Immunizations
|
Elements: Vaccine, Administration Date, and Status Included in Types:
Data Entered in: Medical History > Immunizations > Add Immunization |
Referral Information |
Elements: Sending Provider, Receiving Provider, Office Contact, Scheduled Date, and Referral Reason Included in Types:
Data Entered in: Medical Summary > Prepare Document > Referral Information section > Add Referral |
Discharge Instructions
|
Elements: Instruction and Charted Date/Time Included in Types:
Data Entered in: Patient Chart > Documents > Patient Education (Facility-Based). Note: Only instructions that are defined as PE Category Type = Discharge Instructions in CD> Master Files> Patient Chart> Care Management> Patient Education> Category display in this section. |
Administered Medications
|
Elements: Medication, Dosage, Route, Frequency, and Last Administered Date/Time Included in Types:
Data
Entered in: eMAR > Administer (Also includes Home Medications
and Immunizations that have been administered.) |
Encounter Diagnosis |
Elements: Encounter Diagnosis Included in Types:
Data Entered in: Patient Registration > Admitting Diagnosis |
Reason for Hospitalization (inpatient types) |
Elements: Reason Included in Types:
Data Entered in: Patient Registration > Admitting Diagnosis |
Encounter Information |
Elements: Admission Date, Discharge Date, and Location of Visit Included in Types:
Data Entered in: Patient Registration > Registration Date/Time, Patient Registration > Discharge > Discharge Date/Time, and Patient Registration > Master Files > Facility > Address). |
Reason for Visit (outpatient types) |
Elements: Reason Included in Types:
Data Entered in: Scheduling > New Appointment > Reserve > Comment field (Reason for Visit) |
Diagnostic Tests Pending |
Elements: Description and Scheduled Date/Time Included in Types:
Data
Entered in: CPOE > Lab and Rad Department Orders.
Note: Document includes all
Lab and Rad orders that have not been moved to a complete status,
including Preliminary Lab Results. |
Clinical Instructions |
Elements: Instruction and Charted Date/Time Included in Types:
Data Entered in: Patient Chart > Documents > Patient Education (Facility-Based). Note: Only instructions that are defined as PE Category Type = Clinical Instructions in CD> Master Files> Patient Chart> Care Management> Patient Education> Category display in this section. |
Future Appointments |
Elements: Appointment, Appointment Type, and Appointment Date/Time Included in Types:
Data Entered in: Scheduler > Appointments (future) |
Future Scheduled Tests |
Elements: Procedure and Scheduled Date Included in Types:
Data
Entered in: CPOE > Add Order > Future Visit
Order |
Recommended Patient Decision Aids |
Elements: Instruction and Charted Date/Time Included in Types:
Data Entered in: Patient Chart > Documents > Patient Education (Facility-Based). Note: Only instructions that are defined as PE Category Type = Patient Decision Aids in CD> Master Files> Patient Chart> Care Management> Patient Education> Category display in this section. |