Clinical Summary is a query based data model. It provides a focused snapshot of a patient’s chart containing multiple sections detailing everything from allergies and medications to social history and therapy. This functionality leverages data transmission standards implemented as part of Meaningful Use Stage 2 and can be thought of as similar to HIE transmissions of patient records (but on an application-to-health-system basis).
Key information included:
- Advance Directives: lists advanced directive documents the healthcare organization has on file for the patient.
- Allergies: lists and describes any medication allergies, food allergies, or reactions to other substances (such as latex, iodine, tape adhesives). At a minimum, it should list currently active and relevant historical allergies and adverse reactions.
- Encounters: lists the patient’s past encounters with the health system and associated diagnoses.
- Family History: contains entries for a patient’s relatives and their health problems.
- Immunizations: lists the patient’s current immunization status and pertinent immunization history.
- Medical Equipment: lists any medical equipment that the patient uses or has been prescribed.
- Medications: contains the patient’s past, current, and future medications.
- Plan Of Care: contains future appointments, medications, orders, procedures, and services that a patient may be scheduled for or is waiting to be scheduled for.
- Problems: contains the patient’s past and current relevant medical problems.
- Procedures: documents three types of things: diagnostic procedures, procedures that change the body, and services performed by clinical staff.
- Results: provides results from laboratories, imaging procedures, and other procedures.
- Social History: contains information such as tobacco use, pregnancies, and generic social behavior observations.
- Vital Signs: contains all vital sign readings for a patient recorded over time.
With its abundance of information, the Clinical Summary data model is one of our most frequently used. Common use cases include:
- Acquire patient’s list of medications (past and present).
- Use data as part of the algorithm for risk scoring.
- Populate and provide patient access to Personal Health Record.