Clinical Summary – An after-visit electronically-generated summary that provides a patient with relevant and actionable information and instructions listed below:
- Patient name.
- Provider's name and office contact information.
- Date and location of the visit.
- Reason for the office visit.
- Current problem list.
- Current medication list.
- Current medication allergy list.
- Procedures performed during the visit.
- Immunizations or medications administered during the visit.
- Vital signs taken during the visit (or other recent vital signs).
- Laboratory test results.
- List of diagnostic tests pending.
- Clinical instructions.
- Future appointments.
- Referrals to other providers.
- Future scheduled tests.
- Demographic information
- Smoking status.
- Care plan including goals and instructions.