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.

Summative Documentation Sharing

Summative documentation is suited to automatic sharing, while progress documentation is not, because it can "stand alone" without dependence on other parts of the health record. Summative documents are automatically shared with Alberta's electronic health record (EHR, Netcare). They may also be shared with community electronic medical records (EMR) enabled for eDelivery.

When summative documents are revised (addended) and re-signed, the corrected document is automatically sent to Netcare (and compatible external EMRs) such that the revised document over-writes the old document. Unfortunately, this can create a lot of additional work for community EMRs that rely on manual processes for duplicate reconciliation. Connect Care summative document authors should always "Share" the document while revisions might be indicated. "Sign" only when the document is final and ready for distribution to external systems.

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

Advanced Summative Templates

Templates are also offered in "advanced" or "POC" (problem-oriented charting) forms. These leverage use of shared POC documentation building blocks (e.g., hospital course) to pre-populate the summative document with most of the required information, leaving the clinician to enter or dictate a few remaining text additions. 

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.