Summative Documentation

When documenting at transitions or milestones during or between encounters, "summative" documentation records provide a snapshot of a patient's status at a particular point it time, possibly with respect to a specific health issue. Example include, emergency, admission (history & physical), consultation, operative, transfer, discharge and deceased notes. These gather pertinent information from a patient's past and present, analyze its implications, provide a plan for proceeding and clarify accountabilities. Summative documentation can stand on its own, not depending upon other chart elements to make sense. Accordingly summative records are exchanged with other health information systems, such as the Alberta Netcare Record and community electronic medical records.

Summative documentation can be composed from scratch, usually by dictating as clinicians have (historically) dictated letters. Connect Care additionally supports structured summative documents that pull relevant information in from the rest of the patient's chart. If the health record is well maintained, including use of purpose-build charting tools (problem and medication lists, patient care coordination notes, hospital course notes, goals of care, etc.), then summative tasks can be fast and effective.


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