Encounter Summary Documents vs Patient Summary Documents

OBJECTIVE: To drive out the differences in the CDA header between Encounter Summary documents vs Patient Summary Documents

 

Background Patient Information:   Patient A has the following medical history before the hospital encounter:

Medications

  • Lisinopril – 1 capsule once per day in the morning – prescribed June 2015

Problems

  • Hypercholesterolemia (high cholesterol) – diagnosed June 2015

 

Scenario – Part 1: Patient A was admitted to a hospital on June 6, 2017 complaining of abdominal pain.  On admitting, he had a fever of 101 degrees Farenheit.  He informed the admitting nurse that he also had pain while urinating.  The attending physician diagnosed him with appendicitis and he was admitted for an appendectomy.  Upon discharge on June 8 th , 2018, the patient was given a prescription for Cefotaxime (Claforan or Mexfotoxin are trade names).

 

Document #1 : A discharge summary document was created upon discharge and sent to the patient’s general practitioner.

 

Background Patient Information:   Patient A has the following medical history that was entered after the hospital encounter:

Medications

  • Lipitor – 1 tablet once per day in the morning – prescribed August 2017

Problems

  • Hypertension (high blood pressure) – diagnosed August 2017

 

Scenario – Part 2: On July 6 th , 2018, Patient A requested a summary of his healthcare from the EHR where the procedure took place.  This summary includes details of his appendicitis, his appendectomy, his antibiotic prescription, plus assorted other healthcare details (i.e. your system can include other details and sections as you see fit).

 

Document #2 : A CCD document was created that had medical details including the details in the earlier discharge summary document.