"Entire" Patient Summary: (1) I often have to do "Chart Summaries" for insurance companies. They want "the whole thing". (2) When a patient's file is transferred to another doctor ... an entire patient summary is needed. (3) If a locum was in and was a technophobe, a patient summary could be generated for the doctor. (4) Might be nice to get a "One (LONG) Page" (no clicks neeeded, just scrolling) Summary of the patient incase you don't remember the patient well. The way I invision it is a 1 button click and the massive thing is generated. I could see this button at the top of the Patient>Details>Personal & Contact> Tab. Of course it would make a killer popup ! (Information at the speed of thought and fingers is where it's at !) What would be included in this "One Page Patient Summary" (alot !) Entire Personal info, Address Info, Chart Number, Phone numbers, PHCP, List of Doctors, Photo, Insurance Info, Miscellaneous Info (if not blank), Dates and reasons for the last 20 appointments, Problem List,Social History, Last 2 years of Text Results, Last 2 years of Numerical Data, maybe Portal Messages, Diagnoses, Surgeries, Ticklers, Medications (current, one time, old), Medication History (last 2 years), Names of Completed forms in the last 2 years, Last 3 previous consults. I think that's it. It might be nice to be able to choose what elements you want .... of course that would take some extra coding. It would be similar to the DOCS button (see below).
That's actually possible now to dump the whole patient record print out all the results as we have been discussing print the doc with all the options print all the consults ( there is a print all option above the list of visits table )
Here is one approach to the patient summary - Patient Profile Summary - Current Medical Info - PastMedical Hx, Meds, Allergies, Immunizations, Other Hx - Surgical Hx, FHx, RF, Consults, Hospitalizations Investigations - Lab Results, Investigations, Blood Type ? Patient Details - Personal, Emergency Contacts, Specialist Details, Third Party Insurance.
I am still thinking of how a Patient Summary might work in Synapse. Think: (1) I forget this patient ... I want a 45 second summary. (2) I am not the patient's usual doctor ... I want a 45 second summary. (3) I am a specialist - give me a 45 second summary (one two pages maximum)(need to be faxed !). (4) I am anurse or medical ... I want a 45 second summary. (but I have 5 minutes to read it !)
CCR compatibility. In current form, the CCR standard covers free text, structured text, or coded data for 17 modules: Patient demographics, Insurance information, Advance directives, Problems/diagnoses, Allergies and alerts, Medication list, Immunizations, Family history, Social history, Vital signs, Results, Procedures, Encounters, Medical equipment, Plan of care, Health care providers, Functional status. =-=-=-=-=-=-=-=-=-=-=-=-=- red = dont really have, orange = only minimal function. We should have all of these.
The information can only be output if it's there in the first place ... So, a summary of whatever has to be written first..
There are two issues here: (1) a summary that can be printed. (2) a viewable patient summary. Q: Do we need a "Summary" tab ? is there a better name ? In Ontario land we call it a CPP (Cumulative Patient Profile).
Hmmmm. I suppose. Problem is I have to EDIT a visit to view it. That certainly detracts from it's feeling as a patient summary. I've never seen a patient summary / "home page" where you need to either create a new visit or edit an old one just to get to it. Really that's more of an idealized "office visit" note generation area vs. a summary area. Certainly in a multi provider atmosphere, I wouldn't want a nurse editing my consult note, just to see a good patient summary. I also don't want to look as if I edited a visit note, just because I wanted to see the patient summary.
We need a patient Summary Tab. Yes it is convenient having alot of key information about a patient available when you are doing a consult note. This will not function as a Patient Summary Tab. As far as I am aware, every EMR I have ever seen has a Summary Section. We need to show off how much information about a patient we can get to the hands of the person wanting it and how fast and peppy the Synapse GUI is. The Summary Tab will be a great way to show off. Admittedly we could take many of the ideas from the Consult Editor directly to the Patient Summary Tab, such as ("Text Tab", Graphs, Last 3 visit notes - would be the ones I would bring to the Summary Tab.) Others needed: Dates of Last 10 Visit Notes - with Tags. Numeric Data - HMGs due. Active Ticklers. Medications Surgeries and Procedures. Allergies Diagnoses. Social History: occupation + Social History Summary. Doctors Pharmacy - maybe a picture. Will complete this later.
I need my staff (secretary) to see the patient summary. Obviously, most doctors won't want their staff to be able to edit their consults.
One problem with a MEGA summary is that it requires alot of queries to the database, and can be considered "Expensive" from an efficiency standpoint. Here would be a work around.
Summaries are important but I suspect that you have to write a summary to get the information you want, and not generate them. But if you didn't know, Synapse can generate a CCR