Digitally Upload the Summary on Patient's Epic Record
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Send Notification to Patient about Uploaded Summary
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Ensure the Security of the Shared Summary
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Maintain Audit Trails of the Summary Processed
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Prepare for Next Patient Visit
Patient Check-out from Clinic
Ensure the smooth and efficient check-out process for the patient. Guide them through the necessary steps and provide any assistance they may need. This task marks the end of the patient's visit to the clinic, allowing them to move on with their day. The desired result is a satisfied patient with all necessary paperwork completed. Have you provided the patient with their copy of the visit summary and any required prescriptions or documents?
Compile Patient's Clinical Encounter Data
Gather and organize all relevant clinical encounter data for the patient. This includes medical history, current complaints, physical examination findings, vital signs, and any additional relevant information. Carefully review the patient's electronic medical record to ensure accuracy and completeness. Are all relevant details from the patient's clinical encounter recorded?
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Medical history
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Current complaints
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Physical examination findings
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Vital signs
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Additional relevant information
Include Lab Test Results in Summary
Incorporate the patient's lab test results into the visit summary. This includes any blood work, imaging studies, or other diagnostic tests that have been conducted. Ensure that the results are accurate and clearly documented. Have you reviewed the patient's lab test results and included them in the summary?
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Blood work
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Imaging studies
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Other diagnostic tests
Incorporate Medical Prescriptions into Summary
Include any medical prescriptions given to the patient during their visit. Clearly indicate the medication name, dosage, frequency, and any special instructions. Verify that the prescriptions are accurate and appropriate for the patient's condition. Have you incorporated the medical prescriptions into the visit summary?
Add Medical Recommendations in Summary
Document any medical recommendations provided to the patient. This may include lifestyle changes, follow-up appointments, or referrals to other healthcare professionals. Ensure that the recommendations are clear and actionable. Have you included all relevant medical recommendations in the visit summary?
Interpretation of the Visit by the Doctor
Review the patient's clinical encounter data, lab test results, medical prescriptions, and recommendations. Provide an interpretation of the visit, summarizing the key findings and explaining the medical rationale behind the treatment plan. Ensure that the interpretation is concise, accurate, and easy to understand. Have you provided a clear interpretation of the visit in the summary?
Combine all Data into a Draft Summary
Merge all the collected data, lab test results, medical prescriptions, and recommendations into a comprehensive draft summary. Organize the information in a logical manner, ensuring that it is easy to read and understand. Have you combined all the data into a draft visit summary?
Approval: Doctor Review
Will be submitted for approval:
Combine all Data into a Draft Summary
Will be submitted
Make Necessary Amendments after Approval
Review the draft summary and make any necessary amendments or corrections based on feedback from the approving authority or the patient. Ensure that the final summary accurately reflects the patient's visit and addresses any concerns or issues. Have you made all the necessary amendments to the summary after approval?
Finalise the Visit Summary
Review the amended summary and finalize it for distribution. Ensure that all the required information is included, accurate, and well-presented. Once finalized, the summary represents the official record of the patient's visit. Have you reviewed and finalized the visit summary?
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Check for accuracy and completeness
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Ensure proper formatting and organization
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Obtain necessary approvals
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Verify inclusion of all relevant information
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Remove any patient-specific identifiers
Print the After Visit Summary
Print a physical copy of the visit summary for the patient. Ensure that the document is clear, legible, and properly formatted. Hand over the printed summary to the patient for their reference and future healthcare needs. Have you printed the after visit summary for the patient?
Close the Patient's Clinical Encounter in Epic
Update the patient's electronic medical record in Epic to reflect the completion of their clinical encounter. Close any open tasks, update status codes, and mark the visit as concluded. This step ensures accurate documentation and prevents any confusion or duplication of healthcare services. Have you closed the patient's clinical encounter in Epic?
Handover Summary to the Patient
Physically hand over the finalized and printed visit summary to the patient. Provide a brief explanation of the contents of the summary and its importance for their ongoing care. This step ensures that the patient has access to their visit information and can make informed decisions about their health. Have you handed over the visit summary to the patient?
Digitally Upload the Summary on Patient's Epic Record
Upload the finalized visit summary to the patient's electronic medical record in Epic. Ensure that the document is properly filed and linked to the patient's unique identifier. This step facilitates easy access to the summary for healthcare providers and assists in continuity of care. Have you digitally uploaded the visit summary to the patient's Epic record?
Send Notification to Patient about Uploaded Summary
Send a notification to the patient to inform them about the uploaded visit summary in their Epic record. Provide brief instructions on how to access the summary and emphasize its importance for their ongoing healthcare. Have you sent the notification to the patient about the uploaded visit summary?
Ensure the Security of the Shared Summary
Take appropriate measures to ensure the security and confidentiality of the shared visit summary. This includes protecting patient information from unauthorized access, using secure transmission methods, and following HIPAA regulations. Have you implemented the necessary security measures to protect the shared visit summary?
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Encryption
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Access controls
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Secure transmission
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HIPAA compliance
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Patient consent
Maintain Audit Trails of the Summary Processed
Establish and maintain audit trails for the processed visit summary. This includes documenting all activities related to the summary, such as who accessed, modified, or shared the document. Audit trails enhance accountability, traceability, and data integrity. Have you established and maintained audit trails for the processed visit summary?
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Access log
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Modification log
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Sharing log
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Complete log
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Custom log
Prepare for Next Patient Visit
Ensure that all necessary preparations are made to facilitate the next patient visit. This includes restocking supplies, cleaning the examination room, updating schedules, and coordinating with other healthcare professionals. By adequately preparing, the clinic can provide efficient and timely care to the next patient. Have you completed all necessary preparations for the next patient visit?
