Objective
Provide clinical summaries for patients for each office visit.
Description
Clinical summaries must be provided to patients for more than 50% of all office visits within one business day. The summary must contain an updated medication list, laboratory and other diagnostic test orders, procedures, and other instructions based on clinical discussions that took place during the office visit.
To review the required elements in a Clinical Summary report, see the CMS Tipsheet at:
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/
Stage2_EPCore_8_ClinicalSummaries.pdf
Performance metric
Denominator
Count of clinical encounters with an encounter type of Office Visit, Office Visit Prev. Med., Prenatal Visit, and Telemedicine Visit.
Numerator
Portion of the denominator where a clinical summary is printed within one day and linked to the clinical encounter.
Ratio
The resulting percentage must be more than 50%.
Exclusion
Any eligible provider who has no office visits during the EHR reporting period.
Notes
A printed clinical summary automatically amends the clinical encounter if done on the same day; a provider will receive credit if the Clinical Summary Refused check box is selected.
Configuration
Access levels
All operators who will be providing the Patient Clinical Summary report must have access to do so.
Access Levels > Reports > Records Reports > Patient Clinical Summary Report Operators who will be providing the Patient Clinical Summary report also must have access to all chart sections from which data will be included in the Patient Clinical Summary report.
System configuration Chapter 8 - Core Objective 8 - Clinical Summary
Access Levels > Records > (all desired chart sections)
If clinical summaries are provided electronically via the RelayHealth portal, access to the external systems is required for users performing the necessary configuration.
Access Levels > General > External Systems/Proxy Settings
If clinical summaries are provided electronically as a CCDA file, the user generating the file must have access to the Export Medical Summary feature and access to all sections of the chart from which data will be included in the CCDA.
Access Levels > Reports > Records Reports > Export Medical Summary
Steps for adding and editing access levels have not changed since previous versions of the product. Follow the same process as before.
System configuration
To set up a chart tab to capture the patient instructions to be included in the Patient Clinical Summary report:
Check to see if a chart tab named Patient Instructions (or similar) exists in your system.
If the tab does not exist, complete the following steps.
1. Select Maintenance > Configuration > Customize Patient Chart for Site. The Patient Chart Configuration for Site screen appears.
2. Click on any Undefined chart tab and rename it Patient Instructions. McKesson strongly recommends that you change only Undefined chart tabs. Do not change any existing chart tabs.
To configure the Patient Clinical Summary report defaults:
1. Select Maintenance > Configuration > Special Features. The Special Features screen appears.
2. Select the Records 9 tab.
3. Select the check boxes for items you would like to appear by default on the report.
4. In the Patient Instructions field, indicate which chart tab will be used for patient instructions.
Chapter 8 - Core Objective 8 - Clinical Summary System configuration
5. Select the Text Results Chart Sections check box and then click the ellipses button. The Text Results Chart Sections screen appears.
Figure 34. Text Results Chart Sections screen
6. Select the check boxes for all of the areas from which you want data to be included on the Patient Clinical Summary report.
7. Click the OK button to close the Text Results Chart Sections screen.
8. Click the OK button on the Special Features screen.
For the settings to take effect, you must completely exit the program and re-enter.
To send an electronic Patient Clinical Summary report via RelayHealth Portal:
1. Select Maintenance > Set Up > External Systems. The External Systems screen appears.
Figure 35. External Systems screen
Configuration notes Chapter 8 - Core Objective 8 - Clinical Summary
2. Select Clinical Summaries to RelayHealth and click the Edit button. The Clinical Summaries to RelayHealth screen appears.
Figure 36. Clinical Summaries to RelayHealth screen
3. Select the Schedule Active check box to enable the Scheduling details fields.
4. Enter the schedule time details and enable the data required to be included in the clinical summary using the check boxes in the Content section.
5. Click the OK button to save the changes.
Chapter 8 - Core Objective 8 - Clinical Summary End user training
End user training
To print a Patient Clinical Summary report on paper:
Method 1:
1. Select Reports > Patient Records > Print Clinical Summary for Patient. The Patient Lookup screen appears.
2. Search for and select the appropriate patient. The Patient Clinical Summary Report screen appears.
Figure 37. Patient Clinical Summary Report screen
3. Select the appropriate parameters, including date range.
4. Click the OK button to print.
If there are multiple clinical encounters for the same date of service, a list of clinical
encounters displays. The most recent clinical encounter is highlighted. Confirm that this is the clinical encounter you would like updated for the clinical summary objective and click the OK button.
End user training Chapter 8 - Core Objective 8 - Clinical Summary
If there is no clinical encounter in the system for the date of service, the system prompts you to create a new clinical encounter.
Figure 38. Clinical Encounter Not Found screen Method 2:
1. Open the patient’s chart.
2. Click the Print Cl. Sum. button. The Patient Clinical Summary Report screen appears.
3. Click the OK button to print.
If there are multiple clinical encounters for the same date of service, a list of clinical
encounters displays. The most recent clinical encounter is highlighted. Confirm that this is the clinical encounter you would like updated for the clinical summary objective and click the OK button.
If there is no clinical encounter in the system for the date of service, the system prompts you to create a new clinical encounter.
As best practice, McKesson recommends that you always create clinical encounters prior to printing the clinical summary. Avoid creating the clinical encounter when printing the clinical summary. This will help mitigate issues with duplicate encounters that may skew metrics numbers for several objectives.
To create an electronic Patient Clinical Summary report:
NOTE: These files are not encrypted. See HIPAA guidelines before transmitting electronically.
Chapter 8 - Core Objective 8 - Clinical Summary End user training
clinical encounter you would like updated for the clinical summary objective and click the OK button. The Render to file screen appears.
Figure 39. Render to file screen
4. Select the option for the desired output format: RTF, HTML, or Text.
5. Click the Browse button and navigate to the location where you want to save the report.
6. Enter a file name in the Filename field and click the Open button.
7. Click the OK button to run and save the report in the location of your choice.
McKesson recommends that you follow a standard naming convention to be used by all users (for example, FNameLNameDOS) and create shared folders on the network where all of these summaries can be saved and accessed easily.
Method 2: CCDA - Clinical Summary
1. Select Reports > Patient Records > Export Medical Summary. The Export Medical Summary screen appears.
Figure 40. Export Medical Summary screen
2. Select the appropriate parameters, including date range.
End user notes Chapter 8 - Core Objective 8 - Clinical Summary
3. Select CCDA - Clinical Summary from the Document Type drop-down list and click the OK button.
If prompted, perform a search for the desired patient on the Patient Lookup screen.
4. On the Save As screen, navigate to the location where you want the report saved.
5. Enter the file name and click the Save button.
6. On the Export Medical Summary Detail Selection screen, select the desired clinical data elements.
7. Click the OK button to run and save the report.
McKesson recommends that you follow a standard naming convention to be used by all users (for example, FNameLNameDOS) and create shared folders on the network where all of these summaries can be saved and accessed easily.
To send an electronic Patient Clinical Summary report via Web View Portal:
1. With the patient chart open, select Reports > Patient Records > Print Clinical Summary for Patient. The Patient Clinical Summary Report screen appears.
2. Select the appropriate parameters, including the date range.
3. Select the Send As WebView Message check box.
This check box is available only if the patient has been given access to Web View and a valid e-mail address is entered on the Patient screen - General tab.
4. Click the OK button. The patient receives a secure message in Web View with the Patient Clinical Summary report as an attachment (in .pdf format).
End user notes
• When an operator chooses to print the report, the provider defaults to the current provider, although it is possible to print for other providers.
• The Print to Screen and Send a WebView Message options have no effect on this report.
The EHR performance metrics are incremented appropriately when these options are chosen.
• The Save Report option does not increment the performance metrics. It does not update a corresponding clinical encounter.
• If a patient refuses a clinical summary, you may manually select the Clinical Summary Refused check box on the Clinical Encounter screen. This will count for appropriate credit with proper increments to the performance metrics.
Chapter 8 - Core Objective 8 - Clinical Summary End user notes
.CS: X|R: Provider ID: Practice ID: Date: Time: Encounter Code
Consider adding the <<PUSH>> label marker if needed. For more information, refer to the PUSH and ENTER Label Markers topic in the online help.
For more information on the .CS code, see the Dot Code topic in the online help.
Figure 41. Clinical Encounter New screen
• A clinical summary must be provided within three business days of the patient’s visit. If the Patient Clinical Summary report is generated more than three business days after the patient’s visit, it will not increment the performance metrics.
• The Patient Clinical Summary report does not include any data that the current operator does not normally have access to in the specific patient’s chart. This includes any level of blocking access to the data (for example practice-access levels, chart access controls, operator access levels, and lab security levels).
• For ease of workflow, providers may find it beneficial to use the .K and .end Dot codes to send patient instructions from the progress note to the appropriate chart tab, rather than opening the chart tab and creating a separate note. An example of the user of the .K and .end Dot codes with patient instructions might be as follows.
.K: Patient Instructions
[insert patient instructions here]
.end
Consider using the <<PUSH>> label to activate the .K Dot code prior to completion of the note if needed. For more information, see the PUSH and ENTER Label Markers topic in the online help.
End user notes Chapter 8 - Core Objective 8 - Clinical Summary