Denise, ARNP, Typing Up an After Visit Summary
Background
Our electronic medical record allows providers to type after visit summaries (AVS) for patients that are printed off and given to patients when they leave. I see tremendous variation in the quality of these after visit summaries. Because we do not have established standards for the construction of the AVS, it is not surprising to find such variation. In preparation for next week’s Primary Care Forum (a quarterly front line primary care manager meeting), medical center chiefs and clinical operations managers have been asked to review the AVS’s of several providers to see if there might not be a link between AVS quality and access. In doing this homework, I decided to draft some quick definitions of AVS quality.
Seven Measures of AVS Quality
- Summary begins by addressing patient by name (ie, first name or Mr./Ms., as appropriate)
- The diagnosis (or health status, if it is a physical) is stated
- The reason the diagnosis matters is stated
- The actions necessary for the patient to take are stated
- There is some demonstration of empathy in the AVS
- Summary is reasonably well organized
- Summary ends with a typed signature (eg, Martin Levine, MD, Northgate Medical Center)
What do you think about this list? How could it be better?
I completely agree with most of these. I always want to know – what does the patient need and want?
A few years ago the Epic team did a large improvement effort aimed at simplifying the AVS for the standard pieces that appear on it (like the diagnosis for the visit, labs that are due etc) and got some patient input on what worked for them.
For me one key thing is completing the AVS with the patient when we are sitting together in the room. I always try ot have something more than just the medical – something there about our personal conenction – a book recommendation, a refection on an idea they shared, or even a recipe (I have a smartphrase for butternut soup that is to die for!). I think that the AVS should be one more reinforcement of the relationship, rather than just a medical document
“The actions necessary for the patient to take are stated.”
Under this heading, I’d be specific what the patient’s next contact (or few contacts) with GH should be. Visits to the lab, picking up prescriptions, next well visit or follow-up visit, phone calls or group visits, look for your lab results and I’ll call you if XYZ, etc.
I like all these ideas. Another message I got in response to this post (but it was sent via regular email rather than a blog posting), was to incorporate the standards for the AVS mandated by Medicare as part of annual wellness visits. This would mean listing the providers involved in care on an ongoing basis. I do wonder if some functionality like this (including Meredith’s idea about follow up plan) could not be created as a default field through Epic so the provider does not have to free text this. Gwen — can you summarize the findings from Epic about what patients want?
Bravo, Marty! I like all these, plus the additional comments (especially the soup recipe). I also like to include some idea about what the next one or two steps would be if our current plan isn’t working out (e.g. if PT and ibuprofen aren’t working, let’s do an injection, then we’ll get Ortho involved). Acknowledging that a plan might need to be adjusted helps build discussion around care and prevents patient frustration if they’re not seeing improvement.
How do we ensure that we keep the requirements for expected content for the AVS to remain simple and reasonable? Good medical care synthesizes and pulls things together into practical steps. As expectations for health care increase in terms of quality and the pressure to document and measure more increases, how do we make sure that the AVS still is about a paragraph or two, perhaps at most one half of one side of a piece of paper?