Patient Summary introduction

Patient Summary introduction

Introduction

In collaboration with Canada Health Infoway and the Government of Alberta, Healthquest has integrated Patient Summary submissions right from your EMR.

The Canadian Patient Summary (PS-CA) is a standardized collection of patient information used to enhance patient care by having multiple clinicians across disciplines able to contribute to a shared patient record.

Information from the patient's clinic health record is sent right into AB Netcare, enhancing patient safety, supporting transitions of care and helping to create better healthcare outcomes.

Requirements

  1. The provider must be signed up for CII/CPAR. The data upload uses the same pathways as CII, this must be enabled to submit patient data. A Privacy Impact Assessment (PIA) update may be required.
  2. Healthquest's support team will need to enable the feature.
  3. Updated medical history templates will need to be added and completed for the patient's data to flow correctly.

What type of data is uploaded?

  1. Medications
  2. Allergies
  3. Problems
  4. Procedures or surgeries
  5. Vitals
  6. Social History
  7. Family History

Medications

By choosing to select all, you will upload all medications that have been prescribed to the patient, including inactive medications. Simplify this list by sending current medications and only important inactive medications. Use the notes field in the Patient Summary window to provide context for the medication or any applicable information that should be shared. Please be advised the text you enter in this notes field does not copy into the patient's chart.


Allergies

All recorded allergies should be uploaded regardless of severity. Use the notes box in the Patient Summary window  to provide any additional information. Please be advised the text you enter in this notes field does not copy into the patient's chart.



Problems

Problem list items can be uploaded including the problem name, diagnostic code, status and start date. If a problem is resolved it can be uploaded unless you apply an end date to the item. Problem list is a mandatory field, if no problem list items are available you must select an empty reason. Use the notes box in the Patient Summary window to provide any additional information. Please be advised the text you enter in this notes field does not copy into the patient's chart.



Procedures

Procedures and surgeries should be uploaded via Patient Summary, especially if you have record of procedures completed out of the province or that are not available on Netcare. Use the notes box in the Patient Summary window to provide any additional information. Please be advised the text you enter in this notes field does not copy into the patient's chart, but if you use the notes box in the PS-Procedure History charting template, the text will copy into the notes field in the summary window.


Vitals

Vitals can be selected from any of your charting templates. Height, length, weight, BMI and head circumference can all be uploaded. A full history of recorded vitals is not always necessary, upload as many as you deem clinically appropriate. Use the notes box in the Patient Summary window to provide any additional information. Please be advised the text you enter in this notes field does not copy into the patient's chart.



Social History

Tobacco use, alcohol use and other lifestyle information (example: exercise, drug use, living situation/marital status) can be uploaded to Patient Summary. Use the notes box in the Patient Summary window to provide any additional information. Please be advised the text you enter in this notes field does not copy into the patient's chart, but if you use the notes box in the PS-Social History charting template, the text will copy into the notes field in the summary window.



Family History

Upload family history including the relation to the patient, diagnosis, age at onset, death age, cause of death and additional notes. Use the notes box in the Patient Summary window to provide any additional information. Please be advised the text you enter in this notes field does not copy into the patient's chart, but if you use the notes box in the PS-Family History charting template, the text will copy into the notes field in the summary window.


Incomplete Information

If an area of the summary is blank, or you will not be uploading that information, select the reason that no information is being provided.




Sample Patient Summary Report




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