Clinical Summaries for Each Office Visit
Meaningful Use requests that the information include diagnostic test results, patient problem list, medication list, and medication allergy list at a minimum.
This can be accomplished in SOAPware in two ways. The first involves printing the information in the CCR (Continuity of Care Record) format which includes a "snapshot" of the patient's chart for the last 30 days. The second method will be placing the "Clinical Summary Provided" on a Document Design that includes SOAPnote and Summary information.
Both of this methods can be tracked in order to qualify for the Meaningful Use initiatives and will update the MU Patient Dashboard.
*REQUIRED FOR MEANINGFUL USE: CLICK HERE TO VIEW THE MEANINGFUL USE ROADMAP
Patient Meaningful Use Dashboard:
This requirement will be tracked via the Patient Meaningful Use Dashboard.
Creating/Providing a Clinical Summary CCR Document
*Note-CCR (Continuity of Care Record) format includes a "snapshot" of the patient's chart for the last 30 days.
With a patient chart open:
1. Click on the View menu item.
2. Click on MU Patient Dashboard.
The MU Patient Dashboard can be docked.
For instructions on docking tabs, click here
Using a CCR to Provide a Clinical Summary
The MU Patient Dashboard allows the user to export a CCR Document while keeping track of the patient compliance measures for Meaningful Use Requirements.
1. Click on the drop down arrows for Compliance Details (if no details are displayed)
2. Click to select Medical Summary.
Selecting the Printer
The Print dialog box will display. Click to highlight the desired printer and Click on the print button.
CCR Format
The CCR format will appear as above when printed.
Using a Document Design to Provide a Clinical Summary
The command to indicate the Clinical Summary was provided to the patient must be placed on the proper Document Design.
To do this:
1. Click on Tools.
2. Click on Document Designer.
File > Available Designs
1. Click on File.
2. Click on Available Designs.
Selecting the Desired Design
1. Click to highlight the design that includes the Summary and SOAPnote information.
2. Click OK.
Inserting the Command
1. Place the cursor on the design. The location of the cursor and subsequent command is not important as the command runs in the background and is not visible when the design is printed.
2. Click on Data Items.
3. Click on Macros.
4. Click on Clinical Summary Provided.
The Command
The command will not appear on the design.
Saving the Edit
1. Click on Close.
2. Click Yes.
Clinical Summary
This lesson has demonstrated the two ways to provide a Clinical Summary for a patient; CCR document and using a Document Design.
Both methods will be reflected in the MU Patient Dashboard and Meaningful Use Dashboard.