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Visit Summary Handout

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Don Clothier

(@dclothier)

Posts: 19

Eminent Member

Topic starter

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

Posted : April 23, 2012 4:20 am

Don Clothier

(@dclothier)

Posts: 19

Eminent Member

Topic starter

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}

Posted : April 23, 2012 4:54 am

Beth Ann

(@beth-ann)

Posts: 135

Estimable Member

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)

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}

Posted : April 24, 2012 10:48 am

Teresa

(@teresa)

Posts: 27

Eminent Member

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.

Posted : April 25, 2012 4:07 am

C J Torontow

(@cjtorontow)

Posts: 45

Trusted Member

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?

Posted : April 26, 2012 3:15 am

Don Clothier

(@dclothier)

Posts: 19

Eminent Member

Topic starter

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.

Posted : April 26, 2012 3:17 am

Don Clothier

(@dclothier)

Posts: 19

Eminent Member

Topic starter

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!

Posted : April 26, 2012 3:18 am

Don Clothier

(@dclothier)

Posts: 19

Eminent Member

Topic starter

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.

Posted : April 26, 2012 3:19 am

Sam

(@sam)

Posts: 371

Honorable Member

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.

Posted : April 26, 2012 3:21 am

Don Clothier

(@dclothier)

Posts: 19

Eminent Member

Topic starter

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!

Posted : April 26, 2012 3:22 am

Don Clothier

(@dclothier)

Posts: 19

Eminent Member

Topic starter

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.

Posted : April 26, 2012 3:25 am

Sam

(@sam)

Posts: 371

Honorable Member

We are too... you're good. Cool

Posted : April 26, 2012 3:32 am

Don Clothier

(@dclothier)

Posts: 19

Eminent Member

Topic starter

Been zapped once too often! I try to check things out before I get too excited! Wink

Posted : April 26, 2012 3:35 am

sgilkey

(@sgilkey)

Posts: 64

Estimable Member

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!!

Posted : May 17, 2012 12:02 am

Don Clothier

(@dclothier)

Posts: 19

Eminent Member

Topic starter

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.

Posted : May 17, 2012 12:07 am

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