Difference between revisions of "Emergency Department Encounter Summary"

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(New page: WORKS-in-PROGRESS * This profile defines the content sections for Emergency Department Encounter Summaries. It uses HL7 Clinical Document Architecture (CDA) Release 2 and.... __TOC__ =...)
 
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WORKS-in-PROGRESS
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Emergency Department Encounter Summary (EDES) profile is a summary of the patient’s current health status and a summary of care rendered in the ED between arrival and ED departure.
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This profile defines the content sections for Emergency Department Encounter Summaries. It uses HL7 Clinical Document Architecture (CDA) Release 2 and....
 
  
 
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==Summary==
 
==Summary==
  
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The ''Cross-Enterprise Sharing of Medical Summaries'' profile provides a mechanism to automate the sharing process between care providers of Medical Summaries, a class of clinical documents that contain the most relevant portions of information about the patient intended for a specific provider or a broad range of potential providers in different settings. Patient transfers and, therefore, the summary documents that accompany these transfers can be categorized into 3 primary types:  Episodic, Collaborative, or Permanent. Medical Summaries are commonly created and consumed by electronic medical record systems at points in time of one of these types of transfers of care. For example, a referral note is a medical summary used for a collaborative transfer of care whereby a discharge summary is a medical summary reflecting an episodic transfer.
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The EDES is not (yet) intended to replace the ED Chart as a complete, legal document of care, but is intended as a collection of medical summaries with focused scope that can be used to fulfill a number of collaborative transfers of care. The Emergency Department Encounter Summary may include links to diagnostic tests performed during the ED encounter, as well as documentation of an initial [[PCC TF-1/EDR|Emergency Department Referral]], prehospital (EMS) records, and the consultations of other providers.
  
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[[image:xdsms.png|frame|center|The Cross-Enterprise Sharing of Medical Summaries Integration Profile solves the problem of transferring summary patient information between providers in different clinical settings.
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[[image: IHE PCC EDES diagram.png|frame|center|The EDES Profile solves the problem of summarizing a patient’s current health status and the summary of care rendered in the ED between arrival and ED departure.
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.
 
]]
 
]]
  
 
==Benefits==
 
==Benefits==
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* Leverage Clinical Documents ontology
 
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** A common mechanism for transfer of encoded clinical data embedded in documents
 
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* Enhances Clinical Documents criteria for key use cases:
 
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** Inpatient to Primary Care Provider
 
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** Primary Care Provider to Specialist
 
  
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* Leverages HL7 Clinical Documents ontology
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* Addresses problem of inconsistent and variable formats of current paper-based ED summary documents
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* The production and delivery of the Emergency Department Encounter Summary solves a number of problems, including:
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** Communication with and transfer of care back to the patient’s primary care physician.
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** Communication with care providers in the inpatient setting for patients admitted to the hospital from the emergency department.
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* The Emergency Department Encounter Summary could also be employed in:
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** Transfer of information to hospital and provider billing systems.
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** Transfer of information to regulatory and public health agencies requesting data from emergency department encounters.
 
==Details==
 
==Details==
  
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The basic process flow supported by XDS-MS mirrors current manual practices: someone
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The Emergency Department Encounter Summary is a “folder” in XDS that defines a collection of documents. Several content profiles must be included to represent the various kinds of documents that might be found in the EDES Folder.
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gathers the appropriate documents from the patient medical record, copies them, packages them
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up with a cover letter explaining the reason the information is being sent, and then ships the
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These content profiles include:
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package to the receiving provider. This is often accompanied by a telephone call from the
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* ED Triage Note – this documents contains data compiled during the ED triage process.
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sending provider to the receiving provider that indicates that such information is forthcoming.
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* ED Nursing Note – this document contains data complied during the on-going care (after initial triage) of the ED patient.
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* Composite ED Triage and ED Nursing Note – this document can be used in lieu of individual triage and ED Nursing notes by implementers where both above documents may be consolidated into a single document.
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* ED Physician Note – this document is a summary view of ED physician documentation.
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* Prehospital Care Report – this document has been identified as a future work product and is on the PCC Roadmap for 2008.
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* EDR (Emergency Department Referral) – see EDR
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* Diagnostic Imaging Reports – shall be shared using XDS-I.
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* Lab Reports – Laboratory reports shall be shared using XD*-LAB.
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* Other documents which are the subject of future IHE work including: Prehospital Care Report, Consultations, Transfer Summaries, Summary of Death.
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Note: Each of the documents described above may have different authors.  In some cases a single document can have multiple authors. Local policies may require certain documents to be attested to (signed) by the responsible provider, which may again be different from the author or authors.  The content profiles allow for multiple authors to be recorded, and for the attestation (signature) to be provided according to the local policy.
  
 
==Systems Affected==
 
==Systems Affected==
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EHR Systems
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EDIS Systems
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EHR systems used in Primary Care or other ambulatory care settings
  
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==Actors==
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==Actors/Transactions==
 
* [[Content Creator]]
 
* [[Content Creator]]
 
* [[Content Consumer]]
 
* [[Content Consumer]]
  
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==Transactions==
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This profile reflects the combination of a number of individual clinical documents used during an ED encounter.  However, specific to this profile, the following content modules have been specified:
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* Triage Note: The triage note is a CDA document that may be submitted to an ED Folder in order to record the act of triaging a patient upon presentation to the emergency department. The triage note is designed to support a comprehensive triage assessment, although it is recognized that providers may not capture the entire list of sections, owing to patient presentation, acuity or time constraints.
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* Nursing Note: The nursing note is a CDA document that may be submitted to an ED Folder in order to record the act of nursing care delivered to a patient in the emergency department. The ED nursing note is designed to support documentation sufficient to support transfer of care.
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* Composite Triage and Nursing Note: The composite triage and nursing note is a CDA document that may be submitted to an ED Folder in order to record the act of both triage and nursing care delivered to a patient in the emergency department.
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* ED Physician Note: The ED Physician Note is a CDA document that may be submitted to an ED Folder in order to record the care delivered to a patient in the emergency department. The ED physician note is designed to support documentation sufficient to support transfer of care.
  
 
==See Also==
 
==See Also==
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Profile Status: [[Comments| Final Text]]
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Profile Status: [[Comments| Trial Implementation]]
  
 
The [[Frameworks#IHE Patient Care Coordination Framework| Patient Care Coordination Framework]] is the official master document for this Profile.  
 
The [[Frameworks#IHE Patient Care Coordination Framework| Patient Care Coordination Framework]] is the official master document for this Profile.  

Revision as of 15:10, 25 April 2008

Emergency Department Encounter Summary (EDES) profile is a summary of the patient’s current health status and a summary of care rendered in the ED between arrival and ED departure.



Summary

The EDES is not (yet) intended to replace the ED Chart as a complete, legal document of care, but is intended as a collection of medical summaries with focused scope that can be used to fulfill a number of collaborative transfers of care. The Emergency Department Encounter Summary may include links to diagnostic tests performed during the ED encounter, as well as documentation of an initial Emergency Department Referral, prehospital (EMS) records, and the consultations of other providers.

The EDES Profile solves the problem of summarizing a patient’s current health status and the summary of care rendered in the ED between arrival and ED departure. .

Benefits

  • Leverages HL7 Clinical Documents ontology
  • Addresses problem of inconsistent and variable formats of current paper-based ED summary documents
  • The production and delivery of the Emergency Department Encounter Summary solves a number of problems, including:
    • Communication with and transfer of care back to the patient’s primary care physician.
    • Communication with care providers in the inpatient setting for patients admitted to the hospital from the emergency department.
  • The Emergency Department Encounter Summary could also be employed in:
    • Transfer of information to hospital and provider billing systems.
    • Transfer of information to regulatory and public health agencies requesting data from emergency department encounters.

Details

The Emergency Department Encounter Summary is a “folder” in XDS that defines a collection of documents. Several content profiles must be included to represent the various kinds of documents that might be found in the EDES Folder.

These content profiles include:

  • ED Triage Note – this documents contains data compiled during the ED triage process.
  • ED Nursing Note – this document contains data complied during the on-going care (after initial triage) of the ED patient.
  • Composite ED Triage and ED Nursing Note – this document can be used in lieu of individual triage and ED Nursing notes by implementers where both above documents may be consolidated into a single document.
  • ED Physician Note – this document is a summary view of ED physician documentation.
  • Prehospital Care Report – this document has been identified as a future work product and is on the PCC Roadmap for 2008.
  • EDR (Emergency Department Referral) – see EDR
  • Diagnostic Imaging Reports – shall be shared using XDS-I.
  • Lab Reports – Laboratory reports shall be shared using XD*-LAB.
  • Other documents which are the subject of future IHE work including: Prehospital Care Report, Consultations, Transfer Summaries, Summary of Death.

Note: Each of the documents described above may have different authors. In some cases a single document can have multiple authors. Local policies may require certain documents to be attested to (signed) by the responsible provider, which may again be different from the author or authors. The content profiles allow for multiple authors to be recorded, and for the attestation (signature) to be provided according to the local policy.

Systems Affected

EDIS Systems EHR systems used in Primary Care or other ambulatory care settings

Actors/Transactions

This profile reflects the combination of a number of individual clinical documents used during an ED encounter. However, specific to this profile, the following content modules have been specified:

  • Triage Note: The triage note is a CDA document that may be submitted to an ED Folder in order to record the act of triaging a patient upon presentation to the emergency department. The triage note is designed to support a comprehensive triage assessment, although it is recognized that providers may not capture the entire list of sections, owing to patient presentation, acuity or time constraints.
  • Nursing Note: The nursing note is a CDA document that may be submitted to an ED Folder in order to record the act of nursing care delivered to a patient in the emergency department. The ED nursing note is designed to support documentation sufficient to support transfer of care.
  • Composite Triage and Nursing Note: The composite triage and nursing note is a CDA document that may be submitted to an ED Folder in order to record the act of both triage and nursing care delivered to a patient in the emergency department.
  • ED Physician Note: The ED Physician Note is a CDA document that may be submitted to an ED Folder in order to record the care delivered to a patient in the emergency department. The ED physician note is designed to support documentation sufficient to support transfer of care.

See Also

Profile Status: Trial Implementation

The Patient Care Coordination Framework is the official master document for this Profile.

The Medical Summaries FAQ answers typical questions about what the Profile does.

The Medical Summaries Purchasing describes considerations when purchasing equipment to deploy this Profile.

The Medical Summaries Implementation provides additional information about implementing this Profile in software.

This page is based on the Profile Template

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