Here's the visit summary handout I have developed. It utilizes the Patient Instructions CCC form, plus pulls committed assessments from the CPOE-CCC form as well as current problems, meds, allergies, next scheduled appointment, and signed orders.
Any suggestions, comments, additions will be welcome
One comment that comes up often is how to deal with dx that should possibly not appear on a printed form such as abuse, or std. Our current thought is that those should be the 50% not required to print.
Don Clothier
Sr. Systems Analyst
University of Oklahoma Department of Family & Preventive Medicine
Oops - with all that, I forgot to post the actual text. Sorry....
--------------------------------------------------------------------------
CLINICAL VISIT SUMMARY
{DATESTAMP()}
REASON FOR YOUR VISIT: {DOCUMENT.SUMMARY}
Based on your visit today, your provider recommended the following:
{ccc_add_num_with_carriage_ret(obsnow("INSTRUCTIONS"))}
Problems added during today's visit
:
{ccc_add_num_with_carriage_ret(PROB_NEW("List"))}
Problems addressed during today's visit:
{LISTASSESSNEW("full")}
Your complete problems list:
{PROB_AFTER("List")}
Your current medications include:
{if OBSANY("NKMED") = "T" then "None" else "" endif}{ccc_add_num_with_carriage_ret(MEDS_AFTER("List"))}
These medications were added today (if any):
{ccc_add_num_with_carriage_ret(MEDS_NEW("List"))}
Your current allergies include:
{if OBSANY("NKA") = "T" then "No known allergies" else "" endif}
{
ALL_AFTER("list")}
Changes to allergy list (if any):
{ALL_LIST_CHANGES("full")}
Orders added today:
{ORDERS_NEW("list")}
Most recent Vital Signs observed:
{if OBSNOW("HEIGHT") <> "" then "Height: "+OBSNOW("HEIGHT")+" in." else "" endif}
{if OBSNOW("WEIGHT") <> "" then "Weight: " +OBSNOW("WEIGHT") + " lbs." else "" endif}
{if OBSNOW("BMI") <> "" then "BMI: "+OBSNOW("BMI") else "" endif}
{if OBSNOW("TEMPERATURE") <> "" then "Temperature: "+OBSNOW("TEMPERATURE")+ " degrees" else "" endif}
{if OBSNOW("BP SYSTOLIC") <> "" then "Blood Pressure: " else "" endif}
{if OBSNOW("BP SYSTOLIC") <> "" then " Systolic: " + OBSNOW("BP SYSTOLIC") else "" endif}
{if OBSNOW("BP DIASTOLIC") <> "" THEN " Diastolic: "+ OBSNOW("BP DIASTOLIC") ELSE "" endif}
Your next scheduled visit:
{APPT_NEXT()}
Please contact us at the telephone number above if you have any questions or concerns.
M{PATIENT.EXTERNALID}
That looks pretty good Don, thanks. One qustion do you need to also have any lab results which have been recieved in the last 3 days? If so the below information should complete the form.
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)
do
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
endif
endfor
if list <> "" then list else "No lab results." endif
else
"No lab results."
endif}
Don,
Question for you regarding Orders:
Can you indicate how to get any comments/instructions written on the Orders to also translate? I've been struggling with this but it should be very simple.
Teresa E.
Thanks, this is great.
Do you know how MQIC credits the use of the Visit Summary, ie does it need to be saved in the chart?
cjtorontow said:
Thanks, this is great.
Do you know how MQIC credits the use of the Visit Summary, ie does it need to be saved in the chart?
We're guessing you need to check the "record printing in chart" which of course generates another document.
Beth Ann said:
That looks pretty good Don, thanks. One qustion do you need to also have any lab results which have been recieved in the last 3 days? If so the below information should complete the form.
Way cool, Beth Ann! Thanks for sending this!
Teresa said:
Don,
Question for you regarding Orders:
Can you indicate how to get any comments/instructions written on the Orders to also translate? I've been struggling with this but it should be very simple.
Teresa E.
Hi Teresa - We haven't gone down that road.
cjtorontow said:
Thanks, this is great.
Do you know how MQIC credits the use of the Visit Summary, ie does it need to be saved in the chart?
By an audit event triggered when it is printed. No need to use the checkbox to record the handout in the note. The latest releases/KB updates from GE allow the use of an action button to print the handout directly from a VFE form.
Sam said:
cjtorontow said:
Thanks, this is great.
Do you know how MQIC credits the use of the Visit Summary, ie does it need to be saved in the chart?
By an audit event triggered when it is printed. No need to use the checkbox to record the handout in the note. The latest releases/KB updates from GE allow the use of an action button to print the handout directly from a VFE form.
Excellent - thanks, Sam!
dclothier said:
Sam said:
cjtorontow said:
Thanks, this is great.
Do you know how MQIC credits the use of the Visit Summary, ie does it need to be saved in the chart?
By an audit event triggered when it is printed. No need to use the checkbox to record the handout in the note. The latest releases/KB updates from GE allow the use of an action button to print the handout directly from a VFE form.
Excellent - thanks, Sam!
just thinking - which version of EMR? We're on EMR 9.5 still.
We are too... you're good.
Been zapped once too often! I try to check things out before I get too excited!
I remember reading that Peds and Prenatal Patient Instructions, generated from the CCC Print Instructions counts toward Meaningful Use. However, I cannot recall where I found the documentation.
Does anyone know the process to get *Patient Instructions to count and be relevant for peds or prenatal? Thanks!!
We are currently looking at alternate wording for the PEDS side, but I don't have anything definite on it yet. I really think that what we have here will work in a general sense, until we have something better/CMS changes their minds/etc.