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Clinical Summary for MU - What needs to be on the summary?

MU, CQR, PQRS, etc.

Last Post by Anonymous 1 second ago

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tduenas

(@tduenas)

Posts: 58

Estimable Member

Topic starter

Does anyone know exactly what needs to be on the Clinical Visit Summary when printed? Is there an exact description on what all needs to be on there?

Posted : September 21, 2012 12:07 am

gibsonmi

(@gibsonmi)

Posts: 827

Prominent Member

http://www.cms.gov/Regulations.....maries.pdf

Posted : September 21, 2012 12:14 am

chrishuff1

(@chrishuff1)

Posts: 201

Reputable Member

I don't recall where / how I found this in CPS, but there is one already made. Here's a copy of the text that should fulfill this part of meaningful use:

Clinic Visit Date: {sub(str(DOCUMENT.CLINICALDATE),1,10)}
Reason for your visit:

{obsnow("Chief Cmplnt")}

{if obsnow('INSTRUCTIONS') <> "" then "Based on this visit, your provider recommended the following: \n\r" +obsnow('INSTRUCTIONS')+"\n\r" else "" endif}
Problems associated with your visit include:

{if PROB_LIST_CHANGES('full') <> "" then PROB_LIST_CHANGES('full') else "<None>" endif}

Complete Problems list:

{if PROB_AFTER('list','dat') <> "" then "Onset Date Problem Description/ICD Code \n\r" +PROB_AFTER('list','dat') else if LASTOBSVALUE('NKPROB')="T" then "No known problems" else "<None recorded>" endif endif}

Most recent Vitals observed:

{if obsnow("Height") <> "" then "Height: "+obsnow("height")+" inches \n\r" else "" endif}{
if obsnow("Height (cm)") <> "" then "Height: "+obsnow("height (cm)")+" cm \n\r" else "" endif}{
if obsnow("weight") <> "" then "Weight: "+obsnow("weight")+" pounds \n\r" else "" endif}{
if obsnow("weight (kg)") <> "" then "Weight: "+obsnow("weight (kg)")+" kg \n\r" else "" endif}{
if obsnow("BMI") <> "" then "BMI: "+obsnow("BMI")+"\n\r" else "" endif}{
if obsnow("temperature") <> "" then "Temperature: "+obsnow("temperature")+" degrees F \n\r" else "" endif}{
if obsnow("pulse rate") <> "" then "Pulse Rate: "+obsnow("pulse rate")+" beats/minute \n\r" else "" endif}{
if obsnow("pulse rhythm") <> "" then "Pulse Rhythm: "+obsnow("pulse rhythm")+" \n\r" else "" endif}{
if obsnow("resp rate") <> "" then "Respiration Rate: "+obsnow("resp rate")+" breaths/minute \n\r" else "" endif}{
if obsnow("bp systolic") <> "" and obsnow("bp diastolic") <> ""then "Blood Pressure: "+obsnow("bp systolic")+" / "+obsnow("bp diastolic")+" mmHg \n\r" else "" endif}{
if obsnow("bp sys stand") <> "" and obsnow("bp dia stand") <> ""then "Blood Pressure Standing: "+obsnow("bp sys stand")+" / "+obsnow("bp dia stand")+" mmHg \n\r" else "" endif}{
if obsnow("bp sys lying") <> "" and obsnow("bp dia lying") <> ""then "Blood Pressure Lying: "+obsnow("bp sys lying")+" / "+obsnow("bp dia lying")+" mmHg" else "" endif}

Scheduled Appointments:

{APPTS_BY_STATUS("scheduled","FULL")}

Immunizations:

{if GET_FLOWSHEET_VALUES('Enterprise\Printing\Chart_Summary\Immunizations') <> "" then GET_FLOWSHEET_VALUES('Enterprise\Printing\Chart_Summary\Immunizations') else "<None>" endif}

Procedures and Services:

{if ORDERS_NEW("List","S") <> "" then ORDERS_NEW('list','S') else "<None>" endif}

Labs, Tests and Referrals ordered:
(Please see Order sheet for further details)

{if ORDERS_NEW("List","T") <> "" then ORDERS_NEW('list','T') else if ORDERS_NEW("List","R") <> "" then ORDERS_NEW('list','R') else "<None>" endif endif}
{if ORDERS_NEW('list','R') <> "" and ORDERS_NEW('list','T') <> "" then ORDERS_NEW('list','R') else "" endif}

Labs and Tests received in the past 3 days:

{fn fnCVS_LabTestResults()
{local list = ""
local sz, i, dt, tody, lab, dtbegin, dur
local lablist
local labs = GET_FLOWSHEET_VALUES('Enterprise\Interfaces\CCD\Diagnostic Results')
if labs <> "" then
   lablist = getfield(labs, "\n", "")
   sz = 0+size(lablist)
   for i = 1, i <= sz, i = i + 1 do
      dt = ""
      tody = str(._todaysdate)
      lab = lablist[i]
      if size(lab) > 0 then
         dtbegin = match( lab,"/") -2
         dt = sub(lab, dtbegin, 10)
         dur = durationdays(dt, tody)
         if dur < 4 then
            list = list + lab +"\r\n"
         else
            list = list
         endif
      else
         list = list
      endif
   endfor
   if list == "" then list ="No lab results." endif
else
   list="No lab results."
endif
return list
}}{fnCVS_LabTestResults()}

Your current medications include:

{if MEDS_AFTER('list') <> "" then MEDS_AFTER('list') else if LASTOBSVALUE('NKMED')="T" then "No known medications" else "<None recorded>" endif endif}

Your new medications include:

{if MED_LIST_CHANGES() <> "" then MED_LIST_CHANGES() else "<None>" endif}

{fn fnCVS_PatientEducation()
{local list = ""
local sz, i, dt, doty, pteds, dtbegin, dur, firstfilled
local ptedlist
local pted = GET_FLOWSHEET_VALUES('Enterprise\Medicalogic\Patient Education (MU)')
if pted <> "" then
   ptedlist = getfield(pted, "\n", "")
   sz = 0+size(ptedlist)
   list = ""
   firstfilled=0
   for i = 1, i <= sz, i = i + 1 do
      dt = ""
      tody = sub(str(DOCUMENT.CLINICALDATE),1,10)
      pteds = ptedlist[i]
      if size(pteds) > 0 then
         dtbegin = match( pteds,"/") -2
         dt = sub(pteds, dtbegin, 10)
         dur = durationdays(dt, tody)
         if dur==0 then
   if firstfilled==0 then
                firstfilled=1
                list = list + cfmt("Patient Education Provided today:","B","","", "\r\n\r\n", "")
            endif
            list = list + pteds + "\r\n"
         else
            list = list
         endif
      else
         list = list
      endif
   endfor
else
   list=""
endif
return list}}{fnCVS_PatientEducation()}

Please contact us at {LOC.PRIMPHONE} if you have any questions or concerns.

Posted : October 1, 2012 10:03 pm

Mitch Kwiatkowski

(@mitch)

Posts: 111

Estimable Member

Don't forget medication allergies. The GE handout didn't have them when first released, and they are required for MU.

Posted : October 1, 2012 10:29 pm

chrishuff1

(@chrishuff1)

Posts: 201

Reputable Member

Mitch Kwiatkowski said:

Don't forget medication allergies. The GE handout didn't have them when first released, and they are required for MU.

The EP must include all of the items listed under "Clinical Summary" in the above "Definition of Terms" section that can be populated into the clinical summary by certified EHR technology. If the EP's certified EHR technology cannot populate all of these fields, then at a minimum the EP must provide in a clinical summary the data elements for which all EHR technology is certified for the purposes of this program (according to §170.304(h)):
Problem List

Diagnostic Test Results

Medication List

Medication Allergy List

Med allergies are not listed in the "definition of terms", so if I am understanding this correctly, med allergies only need to be listed if your EHR can't populate 11 or so other items.

Posted : October 1, 2012 11:12 pm

kaplan32

(@kaplan32)

Posts: 76

Estimable Member

THIS SOLVED SO MANY PROBLEMS WITH OUT FORM. THANK YOU FOR SHARING

Posted : January 2, 2013 3:37 am

Beth Ann

(@beth-ann)

Posts: 135

Estimable Member

We use something similar: But on a few patients we are receiving an error message under "Labs and Tests receved in the past 3 days": With basically MEL vomit and at the end "no Lab results" endif <Bad index. This only apprears with a few patients. Any idea? Thank you

Name: {PATIENT.FIRSTNAME} {PATIENT.LASTNAME}

Reason for your visit:

{obsany("Chief Cmplnt")}

Based on this visit, your provider recommended the following:

{ccc_add_num_with_carriage_ret(obsany("INSTRUCTIONS"))}

Problems associated with your visit include:

{PROB_NEW()}

Complete Problems list (

The Problem List maintained in this visit summary is comprehensive and arises from diagnoses deemed appropriate by your physicians. Please direct questions about this list to your primary care physician.)

{PROB_AFTER()}

Most recent Vitals observed

{/* vits = GET_FLOWSHEET_VALUES('Enterprise\Printing\Chart_Summary\Current-Vitals')

if vits <> "" then

vitlist = getfield(vits , "\n", "")

sz = size(vitlist)

list = ""

for i = 1, i <= sz, i = i + 1 do

dt = ""

tody = str(._todaysdate)

vit = vitlist[i]

if size(vit) > 0 then

dtbegin = match( vit,"/") -2

dt = sub(vit, dtbegin, 10)

dur = durationdays(dt, tody)

if dur < 4 then

list = list + vit + "\n\r"

else

list = list

endif

else

list = list

endif

endfor

if list <> "" then list else "No results." endif

else

"No results."

endif */}

{if obsany("height") <> "" then "Height: "+obsany("height")+" inches \n\r" else "" endif}{

if obsany("weight") <> "" then "Weight: "+obsany("weight")+" pounds \n\r" else "" endif}{

if obsany("temperature") <> "" then "Temperature: "+obsany("temperature")+" degrees F \n\r" else "" endif}{

if obsany("temp site") <> "" then "Site for temperature: "+obsany("temp site")+ "\n\r" else "" endif}{

if obsany("pulse rate") <> "" then "Pulse Rate: "+obsany("pulse rate")+" beats/minute \n\r" else "" endif}{

if obsany("pulse rhythm") <> "" then "Pulse Rhythm: "+obsany("pulse rhythm")+" \n\r" else "" endif}{

if obsany("resp rate") <> "" then "Respiration Rate: "+obsany("resp rate")+" breaths/minute \n\r" else "" endif}{

if obsany("bp systolic") <> "" and obsany("bp diastolic") <> ""then "Blood Pressure: "+obsany("bp systolic")+" / "+obsany("bp diastolic")+" inches Hg" else "" endif}

Immunizations:

{GET_FLOWSHEET_VALUES('Enterprise\Printing\Chart_Summary\Immunizations')}

Procedures and Services:

{ORDERS_AFTER("List","S")}

Labs and Tests ordered:

{ORDERS_NEW("List","T")}

{ORDERS_NEW("Liat","L")}

Labs and Tests received in the past 3 days:

{labs = GET_FLOWSHEET_VALUES('Enterprise\Printing\Chart_Summary\Current-Labs')

tody = str(._todaysdate)

if labs <> "" then

lablist = getfield(labs, "\n", "")

sz = size(lablist)

list = ""

for i = 1, i <= sz, i = i + 1 do

dt = ""

lab = lablist[i]

labsize = size(lab)

if labsize > 0 then

dtloop = 0

dtptr = 1

while (dtloop = 0) and (dtptr + 11 <= labsize)

dtbegin = match( lab, dtptr,"/") -2

dt = sub(lab, dtbegin, 10)

if sub(lab, dtbegin + 10, 1) = ")" then dtloop = 1 endif

dtptr = dtbegin + 3

endwhile

dur = durationdays(dt, tody)

if (dur < 4) and (dtloop = 1) then

list = list + lablist[i] + "\n\r"

endif

endfor

if list <> "" then list else "No lab results." endif

else

"No lab results."

endif}

Your current medications include:

{ccc_add_num_with_carriage_ret(MEDS_AFTER("List"))}

Your new medications include:

{ccc_add_num_with_carriage_ret(MEDS_NEW("list"))}

Allergy List:

{IF OBSANY("NKA")= "T" THEN "PATIENT HAS NO KNOWN ALLERGIES." ELSE "" ENDIF}{ALL_AFTER()}

Please contact us at_________________________ if you have any questions or concerns.

Posted : January 7, 2013 11:07 pm

gibsonmi

(@gibsonmi)

Posts: 827

Prominent Member

Try this instead

{fn flowsheet_values(){

local labs = GET_FLOWSHEET_VALUE('Enterprise\Printing\Chart_Summary\Current-Labs','DELIM')

local tody = str(._todaysdate)

local list = ""

if labs <> "" then

lablist = getfield(labs, "|", "")

for i = 1, i <= size(lablist), i = i + 1 do

lab = getfield(lablist[i],"^","")

dur = durationdays(lab[3], tody)

if (dur < 4) then

list = list + lab[1] + ": " + lab[2] + " (" + lab[3] + ")" + "\n\r"

endif

endfor

if list <> "" then return list else return "No lab results." endif

else

return "No lab results."

endif}}{flowsheet_values()}

Posted : January 7, 2013 11:45 pm

lkeith

(@lkeith)

Posts: 457

Honorable Member

I know we had that issue as well and we are using the GE Clinical visit summary. Sorry, but I don't remember which piece exactly we had to change but here is the lab section for our handout so if the logic from gibsonmi doesn't work you can take a look at this as well.

Labs and Tests received in the past 3 days:

{fn fnCVS_LabTestResults()
{local list = ""
local sz, i, dt, tody, lab, dtbegin, dur
local lablist
local labs = GET_FLOWSHEET_VALUES('Enterprise\Interfaces\CCD\Diagnostic Results')
if labs <> "" then
   lablist = getfield(labs, "\n", "")
   sz = 0+size(lablist)
   for i = 1, i <= sz, i = i + 1 do
      dt = ""
      tody = str(._todaysdate)
      lab = lablist[i]
      if size(lab) > 0 then
         dtbegin = match( lab,"/") -2
         dt = sub(lab, dtbegin, 10)
         dur = durationdays(dt, tody)
         if dur < 4 then 
            list = list + lab +"\r\n"
         else
            list = list 
         endif
      else
         list = list
      endif
   endfor
   if list == "" then list ="No lab results." endif
else 
   list="No lab results."
endif
return list

Posted : January 8, 2013 12:09 am

Anonymous

(@Anonymous)

Posts: 0

New Member Guest

I'm looking at the path for lab flowsheet and we dont have it set up. If you have this current-labs flowsheet already set up, please share so I can test this script?
Thanks in advance,

[email protected]

Posted : August 26, 2013 6:50 am

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