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, while progress documentation is not because it may not make sense outside of a specific part of the health record.
External System (Netcare, eDelivery) Sharing
Key summative Connect Care documents transfer to Netcare, even if trainees help generate them. The same summative documents are may be automatically routed to primary care providers who have Electronic Medical Records (EMRs) capable of receiving such content via "eDelivery".
Document Types Shared Externally
The following summative documents are configured for exchange to external systems:
Emergency Department Provider Note (summary of ED encounter)
Admitting History and Physical
Labour and Delivery Report
Discharge Summary (including Discharge Summary, Deceased Summary and Inter-facility Summary templates)
Automatic vs Manual Sharing
Emergency and Inpatient summative document sharing automatically routes to the patient's primary care provider (if available). Outpatient summative documentation sharing does not happen automatically. The responsible prescriber needs to indicate if an outpatient communication should be externally shared and, if so, to the primary care provider and/or referring provider. If the communication is appropriate for sharing with external systems, the outpatient provider must use a letter template that includes "Netcare" in its name.
"Quick Click" for Outpatient External Sharing
Prescribers documenting the content of an outpatient consultation in a progress note can instantly mark that note for inclusion into a letter that will route to the primary care provider and/or referring provider while also sending a copy to external systems. This is done with a checkbox at the top of the progress note. The external letter, with progress note included, will route at signing of the outpatient encounter.
Outpatient sharing workflows are faster if personalized. Creation of a few communications 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.
External System Constraints
Connect Care users should be mindful of external sharing when preparing any of the above summative document types. There are limits to what Netcare (and EMRs) can handle. Currently, documents are rendered to "pdf" format for external sharing and may not be accepted if the file size is too large.
When viewed in an external system, the pdf document will not be part of the Connect Care record. Embedded links to Connect Care content will not work. Embedded links to Internet resources (hyperlinks) may not work in the receiving system.
Avoid embedding images or other media that could increase the file size of shared documents. Image(s) are essential to clinical communication (e.g., rash), try to keep the image size small and do not embed more than 2 images.
Corrections and re-Writes
When inpatient summative documents are revised (addended) and re-signed, the corrected document is automatically sent to Netcare (and possibly external EMRs) such that the revised document over-writes the old document. 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.
Once and outpatient letter goes to an external system, by contrast, it is not possible to edit and revise its contents. If necessary, the outpatient letter can be revoked (deleted) within the communications activity. This will send an appropriate message to external systems. A new instance of the letter can then be created using an external systems template.
The Most Responsible Provider is ultimately accountable for accuracy and content of letters, even if support staff contribute, edit or help route the communication.