Event Summaries
Communicare creates Event Summaries in the CDA format compliant with eHealth standards in Australia. Event summaries can then be uploaded to My Health Record or an internal CDA repository.
An Event Summary is a record, reported by a clinician, of significant health care events involving the subject of care.
Prerequisites
The following configuration is required before Event Summaries can be generated:
- Encounter places must have a valid HPI-O configured.
- The current Provider must have a valid HPI-I.
- The patient must have a valid IHI.
- Either My Health Record or an internal CDA repository must be configured. See My Health Record.
Creating and Uploading Event Summaries
When you exit a service, you can send an Event Summary for the patient to My Health Record, if they have a valid IHI.
To upload an Event Summary to My Health Record:
- After you have completed a service, close the Clinical Record.
- In the Service exit window, set Send Event Summary to My Health
Record.
- This option is automatically selected if the patient consents to My Health Record uploads, or if the patient has not been asked whether they consent to My Health Record uploads. See My Health Record Upload Consent.
- If there are no MHR options available in the Service exit window, the patient may not have a valid IHI. Click My Health Record to display information about why an Event Summary cannot be generated.
- If you are exiting a service that is not for today's date, this window is not displayed and you cannot generate an Event Summary.
- Click Yes - This service is now complete.
- In the Service Record window, complete the Medicare details and click Claim now or the Private billing details and click Save. The Event Summary is generated and displayed in the New Event Summary window. Only information from the current service is included.
- In the Event Summary tree view in the right panel, select the information to include in the
Event Summary and exclude any information that is not relevant. The
information included by default depends on whether or not the
Select all Event Summary clinical data items by
default system parameter is set. Include any or all of the
following information:
- Event Details:
- Clinical Synopsis - a clinical synopsis of the event and its reasons, including any qualifiers that have been recorded in this encounter, where the qualifier type has the category of Clinical Synopsis (see ).
- Progress Notes - the progress notes from this service encounter from all providers, including free text and the summary line of each clinical item added to the progress note.
- Adverse Reactions - lists any adverse reactions for the patient that were recorded in the current service. See Clinical Record - Summary Tab.
- Immunisations - lists any immunisation class clinical items that were recorded during the current service. See Clinical Records.
- Diagnoses / Intervention:
- Problem / Diagnosis - lists any condition class clinical items that were recorded during the current service. See Clinical Records.
- Procedures - lists any procedure class clinical items that were recorded during the current service. See Clinical Records.
- Medications - lists any new medications, and any existing medications that are still current. See Medication Summary.
- Diagnostic Investigations - lists any investigation requests or results from the current service. See Investigations.
- Event Details:
- If you want to edit progress notes in the Event Summary:
- Select one of the Clinical Synopsis options.
- Click Edit Clinical Synopsis.
- In the Edit Clinical Synopsis window, add notes anywhere.
- Click Save. These changes do not alter the data recorded in the database, only the event summary.
- To display the history for any data section for which additional data is recorded in the current service, except for the progress notes and clinical synopsis, click Show History.
- When you are happy with the document, click Save and Upload to My Health Record.
Results
The document is queued and is uploaded to My Health Record at the next upload.
If you generate another Event Summary for the same service, Supersede is
set. This option replaces the previous Event Summary uploaded to My Health Record
with a new document from Communicare. You can supersede a document if the following
conditions are met:
- You were the author of the document.
- The HPI-O recorded in Communicare matches the HPI-O of the document.
- The document types match, that is, you can only replace an Event Summary with another Event Summary.
- You have not clicked Save.