Descripción 

Screen where the summary of the patient's clinical information will be displayed.


Access


  • Through the Side Bar section: To access Patient Summary, click the corresponding button on the Side Bar within the Progress Note screen. If the Patient Summary button is missing, click the Settings button on the Progress Note screen's toolbar. Then, choose the Side Bar Settings option. From the available items on the right, drag and drop the Patient Summary item into the items window at the lower left corner of any Side Bar category. Click the Save button to apply the changes. The Side Bar will update, and the Patient Summary button will now be visible under the chosen category.
  • Through the Search section: Click on the Search button located on the left side of the screen, then select the Patient Summary button.


Secciones 


Botones

  • Print: When pressed, it allows to print the CCDA, to be delivered to the patient.
  • Send: When pressed, the clinical summary will be sent to the patient through a CCDA.
    • Email: If you have the e-mail, when you send the information the patient will receive an e-mail with instructions on how to view the information.
    • Direct: If you have a “Direct” account, when you send the information, the patient will be able to log in to the patient portal page with your account to access the information.
  • Export: Allows to export the patient's CCDA.
  • Close: Closes screen. 
  • Patient Declined Summary: When pressed, he identifies that the patient was offered the clinical summary, but did not want it.
  • Name: Displays patient's name and record number.
  • Email: Displays the patient's email address. If the patient already has one registered in the “Patients” screen, it will be displayed in this box.
  • Direct: Displays the patient's portal address. If the patient already has one registered in the “Patients” screen, it will be displayed in this box.
  • What to include: Sections that can be enabled in the CCDA.
  • From/To: To filter dates.
  • Relative Time: Here you can select the relative date of the CCDA. The options are: (They can be filtered by day, week, month, quarter, semester or year).
    • All Time: It will display the information, starting from the date you selected, in the filter field.
    • This: It will display the information recorded for the current day.
    • Previous: It will display the previous day's information.


Secciones del Documento [CCDA]

  • Plan of Care: This section describes the plan of care for a particular patient, for a period of time, for a specific condition. It contains the following sections:
    • Referral to Other Provider: Registered referrals, in the “Add Referral” screen.
    • Future Appointment: Patient's pending appointments, registered in the “Appointment” screen.
    • Scheduled Imaging: Pending images saved, with future dates, in the “Orders” screen.
    • Scheduled Laboratory: Saved pending labs, with future dates or results recorded with the word “Pending” in the “Orders” screen.
    • Scheduled Procedure: Procedures saved with future dates, in the “Orders” screen.
    • Goals & Instructions: Internal referral, which is identified as the objective of treating the patient's condition. This information is filled in, in the “Plan Care” screen.
  • Allergies, Adverse Reactions and Alert**: This section describes the patient's active allergies. These allergies must have an allergic reaction.    


  • Medications**: This section displays the patient's active medications. Information registered in the “Medications” screen.
    • Importante Note: The drug must contain the RxNorm code for the drug to appear in this section.                                                                   
  • Problems**: Displays the patient's active diagnoses. 
    • Important Note: It will only display those diagnoses that are ICD10.
                                                                                   

  • Encounters: Displays the selected diagnosis at the end of the meeting.
    • Important Note: For this information to be displayed, the diagnosis selected must be an ICD10 code and must have “Snomed” assigned to it.                                                                                     
  • Immunizations**: Displays the active vaccines registered to the patient.


  • Social History: Displays the patient's social history, which is filled in the “Smoking Status” screen. Here also, the patient's sex at birth is displayed.


  • Results**: Displays the results of orders registered to the patient. This information is recorded in the “Add Order Result” screen.
    • Important Note: In order for this information to be displayed, the procedures recorded in the lab result must have a “Loinc” number mapped to the “Setting/Clinical/Orders” screen.
  • Vital Signs: Displays the recorded information on the "Vital Signs" screen.


  • Health Concerns Sections: Displays information regarding the patient's concerns.
  • Procedures**: Shows the active procedures that are registered to the patient.


  • Functional Status: Displays the “Functional Status” information, recorded in the “Functional Status” tab, on the “Custom Evaluation” screen.
  • Mental Status: Displays the patient's mental status information. This information is recorded, in the “Cognitive Status” tab, in the “Custom Evaluation” screen and also in the “Evaluation Forms” screen.
  • Goals Sections: Displays the information of the goals and instructions sent to the patient. This information is recorded in the “Plan of Care” screen.
  • Assessments: Display the narrative of the patient's clinical evaluation.
  • Reason For Referral: Displays the reason for which the patient is being referred.
  • Medical Equipment: Displays the medical equipment that the patient uses.

  • Treatment Plan: In this section, the treatment plan to be sent to the patient is displayed.


**These will contain the active history**