Clinical Summary – An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions …

Background and Objective: As part of Affordable Care Act, the Centers for Medicaid Services (CMS) recommend physicians provide patients with an After-Visit Summary (AVS) following a clinic visit. Infor- mation should be relevant and actionable with specific instructions regarding their visit and health.

A good medical summary will include two components: 1) log of all medications and 2) record of past and present medical conditions. Information covered in these components will include: Contact information for doctors, pharmacy, therapists, dentist – anyone involved in their medical care. Current diagnosis.

This article highlights seven specific skills that lead to a clean end to a medical visit and greater satisfaction for both you and your patient.

1. Start with an agenda.
2. Use verbal cues.
3. Address the patient’s emotions up front.
4. Address your own emotions.
5. Have a seat.

After Visit Summary. (AVS) Patients receive an After Visit Summary (AVS) to take home after each visit or hospital stay. The AVS is a print group-based report that shows important information about the care a patient received and any follow-ups or medication changes.

Health information such as diagnoses, treatment information, medical test results, and prescription information are considered protected health information under HIPAA, as are national identification numbers and demographic information such as birth dates, gender, ethnicity, and contact and emergency contact …

Which of the following is required before you can print the AVS? Physician complete medical reconciliation.

The Medical Summary Report

1. Identifying information: name, date of birth, and Social Security number.
2. Physical description, including behavior, mannerisms, and dress.
3. Information and observations that illustrate the applicant’s symptoms and functioning.
4. All of the applicant’s physical and mental health diagnoses.

All patients registered with a GP have a Summary Care Record, unless they have chosen not to have one.

You will receive the final report within 10 days. If you are required to submit corrective action for Requirements for Improvement (RFI), you have 60 days.

You will be required to respond to all RFIs through submitting an Evidence of Standards Compliance (ESC). The Joint Commission will evaluate your plan and follow-up on your progress. Now that you’ve achieved certification, you can publicize it to your stakeholders and community.

At the end of every office visit, we are greeted by a prompt, a soft stop in the system, recommending that an After Visit Summary be printed for the encounter and handed to the patient, to satisfy one of the Meaningful Use requirements.

During the patient visit the provider and the patient make clinical decisions, which the provider enters into the EHR as orders for tests, treatments and referrals. The provider enters these decisions into the EHR as orders. At the end of the visit the provider reviews the AVS with the patient and prints a copy.