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Patient Visit Summary

General Discussion

Last Post by joeg1962 7 years ago

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asears

(@asears)

Posts: 49

Trusted Member

Topic starter

Hello!

We would like to hand patients a quick 1 page summary at the end of the visit for them to take home with them. The summary would include: chief complaint, vital signs, active medications, allergies, test/referral orders entered at the visit, and the Plan dictation. We would be printing this from the form as a handout, so a copy of the summary for that visit is not stored in the Chart (aside from the generic 'handout X was printed' document).

We want to make sure we aren't opening ourselves up to any unnecessary risk of misinterpretation, but feel that patients would appreciate having something in their hand when they leave. Is this something that others are doing? If so, are you having the patient sign anything or the summary itself (which we would then make a copy of to keep for our records as well)?

Thanks!
Bree

Posted : August 30, 2017 1:58 am

rwilliams

(@rwilliams)

Posts: 454

Honorable Member

Wouldn't a Clinical Visit Summary (CVS) accomplish this goal?

Posted : August 30, 2017 2:27 am

asears

(@asears)

Posts: 49

Trusted Member

Topic starter

The CVS doesn't include our Plan dictation or outside orders and it doesn't look as clean due to information we would have to manually remove each time (charges) or doesn't apply to our practice (immunizations, medication admin, etc).

Posted : August 30, 2017 2:42 am

jfitzmd

(@jfitzmd)

Posts: 419

Reputable Member

I've done this and believe it is invaluable. I've include translation of drug administration instructions. I would be glad to share my approach. Contact me directly and i will set up a WebEx to demo

Posted : August 30, 2017 3:05 am

lkeith

(@lkeith)

Posts: 457

Honorable Member

Before MU came about, some of our providers had a "Discharge summary" button on their Assessment/Plan form which printed a handout. The runprocess on the button was {DOCUMENT.TEMP_dn_print_suppress ="yes" "" printhandout("Handouts\Enterprise\Nephrology\Discharge Summary") document.letter_printed_dn="yes" ""}

On the handout we had the various items that they wanted pulled from their assessment plan. An example....

{DATESTAMP()}
{PATIENT.LABELNAME}
{PATIENT.LABELADDRESS}

Discharge Instructions:
{CFMT(DOCUMENT.TEMP_342841226_382_2371633, "", "Labs: ", "B", "
")}
{CFMT(DOCUMENT.TEMP_342841285_382_2371635, "", "Medication Instructions: ", "B", "
")}
{CFMT(DOCUMENT.TEMP_342841251_382_2371634, "", "Other Instructions: ", "B", "
")}
{cfmt(OBSNOW("Disposition"), "", "Disposition: ", "B", "")}{IF OBSNOW("Disposition")= "no follow-up planned" OR DOCUMENT.TEMP_342840583_382_348908 = "tomorrow" OR DOCUMENT.TEMP_342840583_382_348908 = "as needed" THEN cfmt(DOCUMENT.TEMP_342840583_382_348908,""," ") ELSE cfmt(DOCUMENT.TEMP_342840583_382_348908,""," in ","","
") ENDIF}

Maybe this will give you some ideas.

Linda

Posted : August 30, 2017 3:32 am

asears

(@asears)

Posts: 49

Trusted Member

Topic starter

Thank you for your responses! We've already built our handout, but we weren't sure if we needed to have the patient sign anything in order to give it to them. Can we just print it out and hand it to the patient without any documentation of what was given or a disclaimer signed by the patient?

Posted : August 30, 2017 3:36 am

joeg1962

(@joeg1962)

Posts: 843

Noble Member

Clarification Statement -- Can we just print it out and hand it to the patient without any documentation of what was given or a disclaimer signed by the patient?

The answer to this would seem to hinge on what and why you are providing the information. Are you trying to get 'credit' for the handout with a reporting entity?

We provide lots of information to patients at visits, and do not request a signature. For instance, when we give an immunization we print out the CDC VIS sheets. We log the printing internally to prove that it was printed - and we audit compliance regularly - but do not have the patient acknowledge receipt.

Joe Gillis

Posted : August 30, 2017 5:36 am

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