Summative Documentation

When documenting at transitions of care, or at milestone events during an encounter, "summative" documentation is used to capture a snapshot of a patient's status. Summative documentation gathers information pertinent to an encounter, organizes observations, exposes meaning and offers a plan keyed to goals.

Examples of summative documentation include admission history & physical, consultation, operative and discharge notes. These sift information from a patient's past and present, analyze implications, clarify accountabilities, and provide a plan for proceeding.

Summative documentation can stand on its own; it does not depend upon the presence of other chart elements to make sense. Accordingly, summative records can be automatically exchanged with other health information systems, such as the Alberta Netcare electronic health record and community electronic medical records.

Summative Documentation Types

The following types of summative documentation are subject to AHS provincial standards (with expectations for style, headings and information ordering expressed in standard templates) and benefit from automated exchange with other provincial information systems.

  • Emergency

    • Emergency Department Provider Note (summary of ED encounter)

  • Inpatient

    • Admitting History and Physical

    • Labour and Delivery Report

    • Operative Report

    • Consultation Report

    • Discharge Summary

        • Deceased Note (unique template applied within the Discharge Summary note type)

        • Inter-facility Transfer Note (unique template applied within the Discharge Summary note type)

  • Outpatient

    • Consult Letter

    • Procedure Report

Summative Documentation Templates

Summative documentation can be composed from scratch, as might occur when clinicians use in-system voice recognition to dictate consult letters. In addition, Connect Care promotes provincially standardized templates for common categories of summative documentation. These templates ensure that the layout, sections and terminology used adheres to AHS provincial standards. Standards make it easier for community clinicians to rapidly review and appreciate key elements of summative documents.

Summative documents can be initiated with standardized templates by using the "Notes & reports" section of the Sidebar when a chart is opened. In many cases, speed buttons are available in chart navigators (e.g., admission, transfer, discharge) to initiate summative documents with AHS provincial templates. And some "new note" workflows detect the context (e.g., deceased) and automatically initiate at note of the right type pre-loaded with options for appropriate templates.

If a choice of summative templates is offered, users can select from a "Blank" note for personalized templates, a headings-only note to ensure that dictations include required sections in a standardized order, a "Basic" template that takes advantage of SmartTools to pull in typical content , and a "POC" or "Advanced" template that works best if problem-oriented charting is in play.

Headings-only Summative Templates

"Headings" templates ensure that the document header (top section) has identifying information expected for summative documents. In addition, provincially standardized section headings are provided in an appropriate style and order. Users can enter or dictate into each section using the wildcards provided.

Basic Summative Templates

Templates are offered in "basic" forms that include common structured data (e.g., problem list, medications, adverse reactions) together with placeholders facilitating dictation of the right content in the right place. 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 documentation tasks can be fast and effective

POC Summative Templates

Templates are also offered in "POC" (problem-oriented charting) forms that leverage use of POC tools to pre-populate the summative document with most required information, leaving the clinician to enter or dictate a few remaining text blocks.

Summative Documentation Customization and Personalization

Both basic and POC templates exist in generic forms that include common content. In addition, specialty variants are available and automatically appear when indicated for particular patient types, provider specialties or facility contexts. New customizations continue to be developed. Users with more specific needs can start with a generic or specialty template, add new content while maintaining the name and order of standardized sections, then save the personalization for future re-use.