Most forms of clinical documentation serve communication. Indeed, one of the commonest forms of communication emulates traditional "mailing" of consultation letters. This can happen when classes of documents are automatically exchanged between different information systems (e.g., eDelivery) or when specific documents are sent to others copied via secure mail, messaging, facsimile or mail.
There are two categories of clinical documentation:
- Summative documentation gathers all information pertinent to an encounter, organizes observations, exposes meaning, and offers a plan. Examples include consultation notes, admission histories, discharge summaries, surgery reports, transfer notes and care paths.
- Progress documentation highlights new or changed findings or otherwise indicates what is unique to a defined period within a larger encounter. Progress notes are transactional documents. They expose clinically important developments since the last summative note.
Summative documentation is well suited to automatic sharing. Progress documentation is not because it may not make sense outside of a specific part of the health record.
Key summative Connect Care documents transfer to Netcare, even if trainees help generate them. Draft or incomplete documentation is clearly marked. The following summative documents are configured for exchange to Netcare:
- Emergency Department Provider Note (summary of ED encounter)
- Admitting History and Physical
- Labour and Delivery Report
- Operative Report
- Consultation Report
- Discharge Summary
- Deceased Summary
- Consult Letter
- Procedure Report
Emergency and Inpatient summative document sharing does not require choices of authors. However, generating a summative outpatient note -- such as a letter to the referring physician or a report about an outpatient procedure -- requires a decision whether to share with Netcare or not. If the communication is appropriate for sharing to Netcare, the provider must use a template that includes "Netcare" in its name.
Outpatient sharing workflows are faster if personalized. Creation of a few speed buttons that include Netcare and non-Netcare template selections allow quick initiation of letters for sharing. Any SmartText (e.g. SmartPhrase) normally used to set up consult or procedure letters can be included in all types of outpatient communications.
There are limits to Netcare's ability to handle shared documents:
- Avoid embed images or other media that could increase the files size of the document
- Ensure that the correct "author" is indicated in the "from" field, as only this will show in Netcare lists
- Once a letter goes to Netcare, it is not possible to addend or edit its contents. If necessary, it can be revoked and a new letter created to replace it.
The Most Responsible Provider is ultimately accountable for accuracy and content of letters, even if support staff contribute or help route. If removed, a letter remains visible in Netcare with a strikethrough to indicate that it is no longer intended to be part of the patient’s current documentation.