Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide – July 2012

Posted on September 10, 2012. Filed under: Health Informatics, Patient Participation | Tags: , |

Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide – July 2012

“Executive Summary

The Centers for Medicare and Medicaid Services (CMS) include the practice of giving a clinical summary to patients after each office visit as an element of Meaningful Use of an electronic health record (EHR) Stage One.

Giving every patient a clinical summary after each office visit is one of the most challenging of all meaningful use elements because of the complexity of both the information flow and the workflows involved.

This document is a guide to help eligible professionals and their organizations gain a better grasp of how to successfully meet the criteria of giving clinical summaries to patients after each office visit. It discusses the two requirements to accomplishing these goals and assists organizations in meeting them.”

… continues

“Clinical Summary—Defined
CMS has defined the clinical summary as “an after-visit summary (AVS) that provides a patient with relevant and actionable information and instructions containing the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.”

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