Description

This screen displays a summary of the patient's clinical information (C-CDA - Consolidated Clinical Document Architecture).

Access

Click on the Patient Summary button on the Side Bar of the Progress Note screen.


Can't find the Patient Summary button?: Click on Settingsbutton on the toolbar of the Progress Note screen, Select the Side Bar Settings option. Select the Patient Summary item from the available items area on the right side of the screen and drag/drop into the items window on the lower left corner of any Side Bar category. Press saveto store the change. The Side Bar panel will refresh and the button will appear under the category where it was added.



Sections

  • Name: Patient's name and record number.
  • Email: Patient's email address.
  • Direct: Patient's direct messaging address.
  • What to include:  Available information segments to include in the C-CDA.
  • Buttons
    • Print
    • Send
      • Email: If no Direct Address is present, the patient will receive instructions on how to open a free account via Microsoft HealthVault.
      • Direct: Sends the C-CDA to the patients' Direct Messagin Address.
    • Export 
    • Close
    • Patient Declined Summary: Documents that the patient declined to receive the summary.


C-CDA Sections

  • Plan of Care: Details the plan of care for the patient for a specific time period or condition. This section includes the following:
    • Referral to Other Provider: Referrals created through the Add Referral screen.
    • Future Appointment: As created in the Appointments screen.
    • Scheduled Imaging: Imaging orders scheduled for a future date.
    • Scheduled Laboratory: Lab orders stored with future dates or orders that are still with a status of Pending.
    • Scheduled Procedure: Procedures scheduled for a future date.
    • Goals & Instructions: References related to treatment (Plan Care screen).
  • Instructions: Displays education provided to the patient (Provided via Patient Education) and information stored through MedLine access.



  • Vital Signs:



  • Medications: Displays Active medication, as stored in the patient's Medication List.
    • Note: All medication must be coded with an RxNorm in order to appear on the C-CDA.



  • Problems: Displays Active diagnosis codes, as stored in the patient's Problem List.
    • Note:  All diagnosis codes must be coded with a valid SNOMED Id.



  • Allergies, Adverse Reactions and Alert: Displays Active allergies and their respective reactions.



  • Results: Displays order results stored in the patient record (As stored in the Orders screen).
    • Note:  In order for lab results to be displayed, all CPT codes associated with stored results must have LOINC codes mapped to them. See: Setting/ Clinical /Orders.


  • Procedures: Displays procedures stored in the patient record.
  • Immunizations: Displays Active vaccine entries stored in the patient record.



  • Social History: Despliega la información que se llena en la pantalla de Smoking Status. 



  • Encounters: Displays the diagnosis associated with the last closed encounter.
    • Nota Importante: All diagnosis codes must be coded with a valid SNOMED Id.



  • Chief Complaint: Displays the chief complaint of the last closed encounter.



  • Functional Status: Displays the documentation recorded in the Functional Status section of the Custom Evaluation screen.