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Patient Summary Sheet
The patient summary worksheet is a one page
document that contains a structured summary of a patient's longitudinal
health information from the electronic medical record. Many EMR systems
can create these summary sheets when properly implemented. The report is
designed to display relevant clinical data and alerts about multiple
chronic conditions. The core purpose is to display the right information
and reminders without overwhelming the busy care manager, clinician, or
patient; it is tied to a patient's known conditions.
The worksheet displays patient demographic
information, specific problems, allergies and conditions, the patient's
current medication profile, and laboratory test results. It is thus
consistent in content with the Continuity of Care Record (CCR). It also
contains content directly related to a patient's problems, such as
disease-specific laboratory results and advisories, and other preventive
care advisories based on available patient information. The worksheet
has data and disease management advisories for diabetes, heart failure,
hypertension, and depression. For example, if a patient had diabetes, an
instance of the patient worksheet for that patient would display
glycosolated hemoglobin (HbA1c) values and lipid profiles, as well as
the last recorded foot or dilated retinal exams. It would also list
recommendations for treatment based on the data and accepted clinical
guidelines; e.g., HbA1c testing recommendations for diabetic patients,
or hypertension evaluation recommendations for patients with multiple
high blood pressure measurements. Finally, it would list available
preventive care data, such as the date of the most recent pap smear, and
give reminders for what preventive care tests were due.
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