ToC+-+Scenario+2+SWG

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**The ToC Use Case and Requirements Workgroup has completed its activities, and is no longer meeting on a regular basis. To view work completed as part of the Scenario 2 Sub-Workgroup, please reference the material below:**

Purpose and Goals:
To complete the applicable diagrams, functional requirements and data set considerations that support Scenario 2: Provider to Patient.

Meeting Summaries:

 * **Meeting Date** || **Meeting Agenda** || **Meeting Summary** || **Date Posted** ||
 * 03/22/11 ||  || [|Meeting Summary] || 03/23/11 ||
 * 03/24/11 || [|Meeting Agenda] || [|Meeting Summary] || 03/24/11 ||
 * 03/25/11 || [|Meeting Agenda] || [|Meeting Summary] || 03/26/11 ||
 * 03/28/11 || [|Meeting Agenda] || [|Meeting Summary] || 03/29/11 ||
 * 03/29/11 || See Scenario 1 Agenda || [|Meeting Summary] || 03/30/11 ||

Participants:

 * **Name** || **Role** ||
 * Greg Smith || Leader ||
 * Ann Clarke || Member ||
 * Audrey Dickerson || Member ||
 * Cyndalynn Tilley || Member ||
 * Dalana Ostlie || Member ||
 * Jim Hansen || Member ||
 * Kimberly Tooles || Member ||
 * Larry Sampson || Member ||
 * Laura Heermann || Member ||
 * Susan Campbell || Member ||

= Content =

The visuals below depict a combination of all events described in the scenario flows which are described in further detail in the tables that follow.

 * Scenario 2: The Exchange of Clinical Summaries to a Patient from One Care Setting to another. ( see sections highlighted in red that are the focus of this scenario )**


 * Assumptions**
 * 1) Receiving facility has provisionally accepted the patient for transfer or referral with patient consent and wants the clinical summary
 * 2) Negotiations between providers is out of band but necessary to assure acceptance of transfer or referral
 * 3) Agreement to receive by other provider and by patient is necessary for actual transfer or referral of patient
 * 4) Same assumptions apply from Scenario 1
 * 5) Scenario 2 does not describe transport or end user site activity.

User Story 1: //See User Story developed by User Story Sub Workgroup on Hospital or ED discharge.//

 * Actors**
 * **Actor** || **Details** ||
 * Provider: Hospital and ED Clinical System || Source ||
 * Patient: The patient's PHR or Patient Portal || Destination ||


 * Setting 1: Hospital or ED from where patient is discharged (sends discharge instructions to patient).**

A patient is being discharged from the hospital or ED. At the time of patient discharge, the discharge message has been prepared within the Hospital EHR by one of the clinicians caring for the patient; who actually does this will depend on the hospital’s workflow. It might be the resident, a hospitalist, an advanced practice nurse or the attending physician of record. Once the discharge message is prepared, it will be forwarded to the attending physician of record’s (APoR) EHR Task List for review and signature.
 * The APoR will review the discharge summary and once approved will notify the hospital to address the discharge message to designated recipients (Note that some EHRs have automated addressing to the PCP capability, based on the PCP data stored in the EHR. Method to message patient may need to be added.).
 * Discharge instructions are given to the patient by his/her nurse or care manager on day of discharge at or a short time before the physical discharge. The facility may elect to provide a simpler more user-friendly form of discharge instructions for teaching purposes. The patient signs that s/he has received the instructions from the nurse (verbally, in writing, and/or electronically). The instructions may be generic, patient specific, or disease specific depending on the facility’s practices and the patient’s needs. The nurse or case manager may make a notation in the EHR that the instructions and other materials comprising the discharge information document set were completed. Patient signature that s/he has participated in design of (shared decision-making) or reviewed and agreed to adhere to the discharge instructions triggers the physical discharge sequence of events and patient transport out of the facility.

The discharge message is comprised of discharge summary and/or discharge instructions. The (electronic) discharge “message” triggers the following electronic events to recipients:
 * 1) Message to PCP: physical discharge of patient is scheduled for today.
 * 2) **Message to Patient (PHR) or to disk: same as above [Note that as a repository of patient information, the PHR should contain the same data as the E.H.R. in the same language so a patient may read it him or herself and transport that record to another provider of her/her choice.]**
 * 3) Message to Patient Care Unit: indicating patient is safe to leave once teaching has been done. This message triggers internal actions of the facility E.H.R. or nurse.

Messages will be sent via secure, direct HIE messaging and/or Direct Messaging. The message arrives in the PCP’s EHR (or Direct Messaging account) before the patient has left the hospital. A copy of the message is retained in the hospital EHR per the hospital’s policies and workflow rules.

Direct HISP or HIE retains message transfer log per the governing Service Level Agreement.


 * Setting 2: Patient**

Message (**//discharge summary and discharge instructions//**) received into Patient’s PHR via secure, direct HIE messaging and/or Direct Messaging. Depending on the specific PHR, patient may receive a notification to access their PHR as there is new information available. Patient (or patient’s authorized proxy) can access the PHR and review the hospital discharge message. Again, depending on the PHR’s functionality the patient may be able to select sections with of the discharge message (that are discrete data elements) to automatically populate the appropriate fields in the PHR. For example, the new reconciled medication list can be selected to upload to the active medication list section of the PHR and the patient can upload any new problems to the problem list. Some PHR’s may have “all or none” functionality allowing the patient to simply determine if they would like to retain to the PHR or delete from the PHR the discharge message.

User Story 2: //See User Story developed by User Story Sub Workgroup on Closed-loop Referral.//

 * Actors**
 * **Actor** || **Details** ||
 * Provider: Any Provider Clinical System || Source ||
 * Patient: The patient's PHR or Patient Portal || Destination ||


 * Setting 1: PCP’s office**


 * Activity:** PCP Physician is in the middle of an encounter (office visit) with a patient and determines that the patient needs to be referred to a specialist. The PCP is documenting the encounter in the EHR and within the EHR prepares the consultation request message to the specialist. The message is addressed to the appropriate specialist and is sent to the specialist’s EHR.

**A copy of consultation request message may be also sent to the patient’s PHR.**


 * Setting 2: Specialist’s office**


 * Activity:** The referral request is processed according to the specific context of the referral. In accordance with practice policies and workflow the specialist reviews the document and orders any additional tests to be performed for the patient prior to the office visit. Discrete data elements from within the message may be promoted to the specialist’s EHR system date, time and source stamped.

When patient arrives at the specialist’s office he/she is registered in accordance with practice policies and workflow. The specialist documents the encounter in the EHR and prepares the consult message to the PCP. Once the message is prepared it is addressed and is sent to the PCP’s EHR. A copy of the message is retained in the specialist’s EHR.

**A clinical summary is sent to the patient.**


 * Return to Setting 1: PCP’s office**


 * Activity:** Message received into PCP practices’ EHR. Once the message is received into the EHR, additional practice variable activities may occur: patient’s message can be directed to a front desk staff EHR work queue for appropriate distribution to additional staff EHR work queues as appropriate to the practice workflows. For example, the front desk staff may schedule a follow-up visit with the patient and add the patient’s consultation message to the PCP’s document task list. If the patient has an assigned Care Manager that follows the patient at an advanced practice care facility (such as a Patient-Centered Medical Home), the consultation message is directed to both the PCP and the Care Manager for appropriate compliance planning. Discrete data elements from within the message may be promoted to the PCP’s EHR system date, time and source stamped. In accordance with practice policies and EHR functionality, the PCP may review and promote to the EHR the new reconciled active medication and problem lists, any new procedures may be accepted into the EHR, and any other new discrete data elements. The consultation message may be retained in its entirety as a permanent part of the patient’s EHR record.

The patient comes for the encounter with the PCP and the PCP documents the encounter in the EHR.

**The patient receives a clinical summary.**


 * Setting 3: Patient**


 * Activity: "Consultation request" message received into Patient’s PHR via Messaging. ** Depending on the specific PHR, patient may receive a notification to access their PHR as there is new information available. Patient (or patient’s authorized proxy) accesses the PHR and may review the consultation request message. Patient (or their proxy) may respond with confirmation or questions. Again, depending on the PHR system's functionality the patient may be able to select sections of the consultation request message (that are discrete data elements) to automatically populate the appropriate fields in the PHR. For example, the patient may upload any new problems to the problem list. Other PHR systems may have “all or none” functionality allowing the patient to simply determine if they would like to retain to the PHR or delete from the PHR the consultation request message.


 * Activity: "Clinical summary" message received into Patient’s PHR ** . Depending on the specific PHR, patient may receive a notification to access their PHR as there is new information available. Patient (or patient’s authorized proxy) logs on to the PHR and may review the **specialist’s consultation message**. Patient (or their proxy) may respond with confirmation or questions. Again, depending on the PHR system's functionality the patient may be able to select sections within the **consultation request message** (that are discrete data elements) to automatically populate the appropriate fields in the PHR. For example, the patient can upload any new problems to the problem list.

12.1.1 Base Flow of Scenario 2
The original source for this event table was developed by the Use Case Simplification SWG.

The Exchange of Discharge Message (Discharge Instructions and Discharge Summary) to Support the Transfer of a Patient from One Care Setting to Another

 * **Step #** || **Actor** || **Event/Description** || **Inputs** || **Outputs** ||
 * 1 || Provider || Order/Address/Request: Discharge Summary and Discharge Instructions to Patient A in EHR (and has been acknowledged by patient) || START || Discharge Summary and Discharge Instruction Request ||
 * 2 || EHR System || Generate and Send: Discharge Instructions to PHR || Discharge InstructionsI Request || Discharge Instructions ||
 * 3 || PHR System || Receive: Discharge Instructions in PHR || Discharge Instructions || Discharge Instructions ||
 * 4 || EHR System || Generate and Send: Discharge Summary to PHR || Discharge Summary Request || Discharge Summary ||
 * 5 || PHR System || Receive: Discharge Summary in PHR || Discharge Summary || END ||

The Exchange of Clinical Summaries to Support the Closed-loop Transfer of a Patient from One Care Setting to Another

 * **Step #** || **Actor** || **Event/Description** || **Inputs** || **Outputs** ||
 * 1 || Provider (PCP) || Order/Address/Request: Consultation request while meeting with patient || START || Initiated Consultation Request ||
 * 2 || EHR System || Generate and Send: Consultation request details || Initiated Consultation Request || Consultation Request ||
 * 3 || PHR System || Receive: Consultation Request in PHR || Consultation Request || Consultation Request ||
 * ||  || **//Note: rows 4-6 will occur for any delivery of a Clinical Summary//** ||   ||   ||
 * 4 || Provider || Order/Address/Request: Clinical summary including specialist's summary || START || Initiated Clinical Summary Request ||
 * 5 || EHR System || Generate and Send: Clinical Summary details || Initiated Clinical Summary Request || Clinical Summary ||
 * 6 || PHR System || Receive: Clinical Summary in PHR || Clinical Summary || Clinical Summary ||

12.1.2 Activity Diagram for Scenario 2
The following is the Activity Diagram to support the events in section 12.1.1.

12.2.1 Information Interchange Requirements of Scenario 2

 * **Initiating System** ||  || **Information Interchange Requirement Name** ||   || **Receiving/Responding System** ||
 * Electronic Health Record System || Send (A.XFER.1) || Discharge Summary || Receives (A.XFER.2) || Personal Health Record System ||
 * Electronic Health Record System || Send (A.XFER.1 || Discharge Instructions || Receives (A.XFER.2) || Personal Health Record System ||
 * Electronic Health Record System || Send (A.XFER.1) || Consultation Request || Receives (A.XFER.2) || Personal Health Record System ||
 * Electronic Health Record System || Send (A.XFER.1) || Clinical Summary || Receives (A.XFER.2) || Personal Health Record System ||

12.2.2 System Requirements of Scenario 2

 * **System Requirement Name** || **System** ||
 * Display Discharge Summary || Personal Health Record System ||
 * Display Discharge Instructions || Personal Health Record System ||

12.3 Sequence Diagrams
The following sequence diagrams describe the messages and order of messages.

14.0 Dataset Considerations
The following messages are described in the previous user stories.
 * Discharge Summary
 * Discharge Instructions
 * Clinical Summary including Consultation Request
 * Clinical Summary

The following sections define the content for each dataset. The SWG did not describe standard content such as:
 * Patient identity.
 * Data to insure transport of the content.
 * Security, auditing and other policy content.
 * Other procedural overhead, etc.

**Dataset for Discharge Instructions:**
The User Stories SWG identified the following content for Discharge Instructions. Discharge Instructions are determined by the discharging provider organization in accordance with local policy, regulations and law. The receiving provider through its EHR system may determine how to incorporate and present the Discharge Instructions.

Message always includes //standard// minimal data set:
 * Demographic information, active //reconciled// medication list (with doses and sig), allergy list, problem list

Message contains also //data set relevant to the discharge summary/discharge instructions context//:
 * follow up/plan of care (e.g., CCD/83 Plan of Care (What patient can do): Forward looking sections (Treatment Plan), treatments, diet, activities, alerts for conditions, future visits (may include several depending on condition) including appointment established. Patient education and information on medication (tied to alerts), disease process, wound care, condition based special considerations, etc.) etc.

Message contains //variable data set relevant to the hospitalization (selected by the clinician who prepared the discharge summary)//:
 * Examples:
 * Procedures during hospitalization
 * Selected medications administered during hospitalization
 * Selected vital signs
 * Emergency contact information
 * Relevant results, reports
 * Wound care (if applicable)
 * Etc.

Substance intolerance Associated Adverse Events || List of allergies which might include allergy to what (e.g., medication. food, environment). Sensitivity. Past and those that have arisen || > **NOTES. Instructions may be more detailed if sent to another provider.** > - Yes/No - has the discharge instruction been reviewed with the patient. > - Yes/No - has the discharge instruction been accepted by the patient, if no then how addressed > - Yes/No - has the patient assisted in the formulation of the discharge instructions ||
 * **Ref.** || **Section** || **Content** || **Additional Notes** ||
 * T.CC.1 || Personal Information || Name, DOB, Next of Kin, Address, Phone Number, Gender, Marital Status, Religion, Race, Ethnicity ||  ||
 * T.CC.5 || Allergies and Other Adverse Reactions || Allergy Type; and Date
 * T.CC.6 || Problem List || Current Diseases & || * List of problems/complaints (what was diagnosis, complaint and/or descriptor of problem/complaints, symptoms).
 * How do these problems/complaints impact interventions, orders or instructions. ||
 * T.CC.16 || Hospital Discharge Medications || Medications names, doses, frequency, route ordered for the patient for after discharge. || * Include the reconciled active medications
 * **NOTES. Instructions may be more detailed if sent to another provider.** ||
 * T.CC.18 || Advanced Directives || A summary of patient's expectations for care || Yes/No - Target is to trigger a conversation. ||
 * T.CC.20 || Immunizations || Immunizations name, dose, route, date administered to the patient || Comprehensive list of immunizations received during the hospital stay ||
 * T.CC.27 || Plan of Care || Proposed interventions and procedures for patient || Subsections include the following (1-7)
 * 1. Goals.
 * 2. Results yet to be received and procedures to be followed up on.
 * 3. Active and scheduled interventions and orders (short term direct instructions [eg. Vital sign checks, labs, etc.] - in the long run as validated by the patient and those contributed by the patient/caregiver).
 * 4. Education Resources/Materials - Patient education needed. To included classes, educational sessions, printed materials along with steps to a specific need.
 * 5a. Diet and Diet/Fluid Restrictions: All instructions that describe the expected diet.
 * b. Restrictions: List of limitations being placed on the diet
 * 6a. Fluids Management (C/N): All instructions that describe the expected fluids and method of administration.
 * b. Restrictions: List of limitations being placed on fluids
 * 7. Activity/Exercise
 * 7. Activity/Exercise
 * T.CC.31 || Medical Equipment - includes assistive devices and is related to functional status || Implanted and External Medical Devices; Dates || * List of devices and where the device is to be secured/prescribed/embedded.
 * Duration of medical devices.
 * History of devices (recalls, S/N, etc.) ||
 * ADDED || Electronic Links ||  || Links to provider or other computer applications for patient results, summaries, etc. ||
 * ADDED || Patient Oriented Embarkation Checklist ||  || List of facility dependent patient oriented items (e.g., pain scale at discharge, last ECG, etc.) ||
 * ADDED || Functional Status (O/N) - ||  || End state/goal expressed/Projected change in functional status (will relate to the goals identified) ||

**Dataset for Discharge Summary:**
The User Stories Sub Workgroup identified the following content for a Discharge Summary. Discharge Summaries are determined by the discharging provider organization in accordance with local policy, regulations and law. The receiving provider through its EHR system may determine how to incorporate and present the Discharge Summary.

Message Contents: Both minimal standard data set and Discharge context relevant data set.

Message always includes standard minimal data set. At discharge the message might include content for the Discharge Instruction as well as Discharge Summary. Discharge Summary content includes:
 * Demographic information, active reconciled medication list (with doses and sig), allergy list, problem list, and reason for admission.

Message contains variable data set relevant to the hospitalization (selected by the clinician who prepared the discharge message). Examples:
 * Procedures during hospitalization
 * Relevant results, reports
 * Wound care (if applicable)
 * Etc.

Hospital and ED discharge is also the focus of several other efforts including individuals and institutions involved in ToC. For instance, the HIE Challenge Grants, Improving Massachusetts Post-Acute Care Transfers (IMPACT). Discussions surrounding the content included in that transfer was provided by Keith Boone (http://motorcycleguy.blogspot.com/2010/11/circle-never-ends.html). Consideration was given to HITSP C32 Version 2.5, Meaningful Use, and CDA. The sections included: Patient Demographics, Patient Contacts, Healthcare Proxy, Current Healthcare Providers, Physician Orders, Nursing Assessment, Patient Assessment, Therapy and Behavior Information, Medication List, Outstanding Tests and Encounters, and Anticoagulation Orders and Wafarin Flowsheet.

Along with input from the Use Case Simplification and Discharge Instruction Sub Workgroups the following recommended sections and data are included in the Discharge Summary. The sections with a are also found in the HITSP C48
 * **Ref.** || **Section** || **Content** || **Notes by Discharge Instructions SWG** ||
 * T.CC.1 || Personal Information [[image:check.gif]] || Name, DOB, Healthcare Power of Attorney, Address, Phone Number, Gender, Marital Status, Religion, Race, Ethnicity ||  ||
 * T.CC.2 || Contact Information || Contact Name, Contact Number ||  ||
 * T.CC.3 || Insurance Information || Insurance Name, Phone #, Group #, Type, Member #, Subscriber Name, Financial responsibility ||  ||
 * T.CC.4 || Healthcare Provider || Provider Name, Address, Phone Number, Type ||  ||
 * T.CC.5 || Allergies and Other Adverse Reactions [[image:check.gif]] || Allergy Type; and Date || List of allergies which might include allergy to what (e.g., medication. food, environment) ||
 * ||  || Substance intolerance || Patient supplied information about reaction ||
 * ||  || Associated Adverse Events ||   ||
 * T.CC.6 || Problem List - Active Problems (R/N)/Chief Complaint (overriding problem at the time of discharge) - chronic illness and congenital problems [[image:check.gif]] || Current Diseases & || List of problems/complaints (what was diagnosis, complaint and/or descriptor of problem/complaints, symptoms). ||
 * ||  || Conditions monitored for the patient and status || How do these problems/complaints impact interventions, orders or instructions. ||
 * T.CC.7 || History of Past Illness/Resolved Problems [[image:check.gif]] || Diseases & Conditions Patient has suffered in the past ||  ||
 * T.CC.8 || Chief Complaint || Description of Patient's Complaint (narrative) ||  ||
 * T.CC.9 || Reason for Transfer || Reason Patient is being referred ||  ||
 * T.CC.10 || History of Present Illness [[image:check.gif]] || Sequence of events proceeding patient's disease/condition ||  ||
 * T.CC.11 || List of Surgeries || List of types of surgeries and dates ||  ||
 * T.CC.12 || Hospital Admission Diagnosis [[image:check.gif]] || List of Hospital Diagnosis and dates ||  ||
 * T.CC.13 || Discharge Diagnosis [[image:check.gif]] || Conditions/Diseases identified during hospital stay and dates ||  ||
 * T.CC.14 || Medications || List of Current Medication Names ; date, route, dose, frequency || Include the reconciled active medications ||
 * T.CC.15 || Admission Medications History [[image:check.gif]] || List of historical medication names, dose, route, frequency, date patient has taken prior ||  ||
 * T.CC.16 || Hospital Discharge Medications [[image:check.gif]] || Medications names, doses, frequency, route ordered for the patient for after discharge ||  ||
 * T.CC.17 || Medications Administered [[image:check.gif]] || Medications administered to patient during the course of an encounter; name, dose, route, frequency ||  ||
 * T.CC.18 || Advance Directives [[image:check.gif]] || A summary of patient's expectations for care || Yes/No, if Yes date of last known ||
 * ||  ||   || Yes/No if POLST form returned ||
 * ||  ||   || Where is last known version/original is located ||
 * T.CC.19 || Pregnancy || Pregnant, Yes/NO ||  ||
 * T.CC.20 || Immunizations || Immunizations name, dose, route, date administered to the patient || Comprehensive list of immunizations received during the hospital stay ||
 * T.CC.21 || Physical Examination [[image:check.gif]] || Physical Findings of the Patient; VS, Biometrics, Review of Systems ||  ||
 * T.CC.22 || Vital Signs [[image:check.gif]] || Patient's Vital Signs ; Heart rate, Resp Rate, Pulse Ox, Temp, B/P, Pain || Including Pain Scale Assessment, Smoking Status ||
 * T.CC.23 || Review of Systems [[image:check.gif]] || Functions of various body systems; Neuro, Derm, GI, GU, Cardiac, Pulmonary, MS, Repro, Nervous, Endocrine ||  ||
 * T.CC.24 || Hospital Course [[image:check.gif]] || Sequence of (name, diagnosis associated with) events and dates from admission to discharge of hospital stay ||  ||
 * T.CC.25 || Diagnostic Results [[image:check.gif]] || Results and dates of Diagnostic Procedures || Corresponding results to the scheduled procedures and interventions. ||
 * ||  || Results and dates of Diagnostic Procedures || Corresponding results to the scheduled procedures and interventions. ||
 * T.CC.28 || Family History || Dates with Disease Suffered, Age of Death, other genetic information ||  ||
 * T.CC.29 || Social History || Patient's beliefs, home life, social/risky habits, family life, work history ||  ||
 * T.CC.30 || Encounters || Current and historical encounters; dates ||  ||
 * T.CC.31 || Medical Equipment - Medical Devices (C/N) - includes assistive devices and is related to functional status [[image:check.gif]] || Implanted and External Medical Devices; Dates || List of devices and where the device is to be secured/embedded. ||
 * ||  ||   || Duration of medical devices. ||
 * ||  ||   || History of devices (recalls, S/N, etc.). ||
 * T.CC.32 || Preoperative Diagnosis || Diagnosis ( Date) assigned to patient prior to surgery ||  ||
 * T.CC.33 || Postoperative Diagnosis || Diagnosis ( Date) assigned to patient after surgery ||  ||
 * T.CC.34 || Surgery Description || Particulars of Surgery (narrative) (images) ||  ||
 * T.CC.35 || Surgical Operation Note Findings || Clinically significant observations found during surgery ||  ||
 * T.CC.36 || Complications Section || Known risks or unidentified problems ||  ||
 * T.CC.37 || Operative Note Surgical Procedure || Date and Description of Procedure Performed ||  ||
 * DI no DS || Discharge Diet [[image:check.gif]] ||  || part of Discharge Instructions ||
 * DI no DS || Functional Status [[image:check.gif]] ||  || part of Discharge Instructions ||
 * DI no DS || Plan of Care [[image:check.gif]] ||  || part of Discharge Instructions ||

**Dataset for Clinical Summary:**
The Use Stories SWG defined the following clinical summary content. Clinical Summaries are determined by the discharging provider organization in accordance with local policy, regulations and law. The receiving provider through its EHR system may determine how to incorporate and present the Clinical Summary.


 * Clinical Summary including consultation request**.

Message always includes //standard// minimal data set:
 * Demographic information, active medication list (with doses and sig), allergy list, problem list, reason for referral, etc.

Message contains //variable data set relevant to the context of the request//:
 * Examples:
 * Cover note describing the clinical impetus for the referral
 * For a cardiologist consultation request: cardiology relevant tests and results such as Cardiac Echo results, Holter Monitor results, etc.; cardiology-pertinent family history, social histories, procedures, PE findings, etc..
 * For a dermatologist consultation request: dermatology relevant tests and results such as skin biopsy path report, image of lesion, dermatology pertinent family history, social histories, procedures, PE findings, etc..
 * Specific example:
 * PCP has worked up a patient who has a working diagnosis of Thyroid Cancer and is referring the patient to an Endocrine Surgeon.
 * Message includes //standard//minimal data set as above as well as PCP-selected referral-specific variable data set. E.g.:
 * //Pertinent PE finding and history of present illness:// 3 month history of a //2 cm R sided, hard thyroid nodule//
 * //Pertinent results and diagnosis:// FNA done 2/28/11 significant for medullary carcinoma, Calcitonin 2700, CEA 7, TSH, T3 Free T4 all normal
 * //Pertinent Additional Diagnoses Medical /Surgical Hx//: significant only for 3 year history of mild obesity, current BMI 30
 * //Pertinent Family History:// significant for Thyroid cancer mother (unknown type). No family history of MEN Syndromes. No family history of radiation exposure.
 * //PCP referral request and determination of responsibility:// Please evaluate for possible MEN II syndrome, surgery, post-operative care, and any special recommendations. I will assume full care status post the procedure.
 * //Reference to shared information with Patient:// I have reviewed all of the above information with the patient and his wife.
 * //Patient did/did not understand what was communicated//


 * Clinical Summary for specialist notes:**

Message always includes //standard// minimal data set:
 * Demographic information, //specialist//-//reconciled// active medication list (with doses and sig when known), allergy list, //specialist//-//reconciled// problem list, specialist recommendations, etc.

Message contains variable data set relevant to the context of the referral:
 * pertinent findings, test or study results, procedures or operations and reports, indication of any specialty ongoing follow up responsibilities, what has been communicated to the patient, patient’s level of understanding of what was communicated, etc.

The sections with a are also found in the HITSP C48
 * **Ref.** || **Section** || **Content** || **Notes by Discharge Instructions SWG** ||
 * T.CC.1 || Personal Information [[image:check.gif]] || Name, DOB, Healthcare Power of Attorney, Address, Phone Number, Gender, Marital Status, Religion, Race, Ethnicity ||  ||
 * T.CC.2 || Contact Information || Contact Name, Contact Number ||  ||
 * T.CC.3 || Insurance Information [[image:check.gif]] || Insurance Name, Phone #, Group #, Type, Member #, Subscriber Name, Financial responsibility ||  ||
 * T.CC.4 || Healthcare Provider || Provider Name, Address, Phone Number, Type ||  ||
 * T.CC.5 || Allergies Other Adverse Reactions [[image:check.gif]] || Allergy Type; and Date || List of allergies which might include allergy to what (e.g., medication. food, environment) ||
 * ||  || Substance intolerance || Yes/No/Unknown, and if Yes or Unknown how does it affect care. ||
 * ||  || Associated Adverse Events || Other history that guide care. ||
 * ||  || Patient supplied information about reaction ||
 * T.CC.6 || Problem List - Active Problems (R/N)/Chief Complaint (overriding problem at the time of discharge) - chronic illness and congenital problems [[image:check.gif]] || Current Diseases & || List of problems/complaints (what was diagnosis, complaint and/or descriptor of problem/complaints, symptoms). Is a list, of diagnosis, complaints some of these may have been resolved and some are active. ||
 * ||  || Conditions monitored for the patient and status || How do these problems/complaints impact interventions, orders or instructions. Discharge instructions usually are for the encounter just ending. ||
 * ||  ||   || Patient's perception or description of problems/complaints Is usually in notes or history. Not part of a formal problem list. ||
 * T.CC.7 || History of Past Illness/Resolved Problems [[image:check.gif]] || Diseases & Conditions Patient has suffered in the past || May be a list with dates onset and/or resolution ||
 * T.CC.8 || Chief Complaint || Description of Patient's Complaint (narrative) || If not listed in the problem list. ||
 * T.CC.9 || Reason for Transfer/Referral [[image:check.gif]] || Reason Patient is being referred || May come from Utilization Review (UR) or Medicare rules, insurance or HMO rules or the patient may be well. ||
 * T.CC.10 || History of Present Illness [[image:check.gif]] || Sequence of events that occurred to change the state of the patient’s health ||  ||
 * T.CC.11 || List of Surgeries [[image:check.gif]] || List of types of surgeries and dates ||  ||
 * T.CC.13 || Diagnosis || Conditions/Diseases identified during hospital stay and dates || Current encounter list only ||
 * T.CC.14 || Medications [[image:check.gif]] || List of Current Medication Names ; date, route, dose, frequency || list of prescribed medications or other medications. Should be the reconciled list (which should have been done on admission) ||
 * ||  ||   || If to be reconciled then list needs to be inclusive of self administered medications (herbals, over the counter) ||
 * ||  ||   || See notes on medication reconciliation regarding expectations such as discontinued medications from inpatient if not included in discharge summary ||
 * ||  ||   || NOTES. Instructions may be more detailed if sent to another provider. ||
 * T.CC.18 || Advance Directives [[image:check.gif]] || A summary of patient's expectations for care || Yes/No, if Yes then date of ||
 * ||  ||   || Yes/No if POLST form returned ||
 * ||  ||   || Where is last known version/original is located ||
 * ||  ||   || Going forward how the "state" and how it affects care ||
 * T.CC.19 || Pregnancy || Pregnant, Yes/NO ||  ||
 * T.CC.20 || Immunizations [[image:check.gif]] || Immunizations name, dose, route, date administered to the patient || Comprehensive list of immunizations (have - patient reported, got, need):* list of immunizations necessary to get after discharge.* list of education or information about immunizations they received while hospitalization ||
 * T.CC.21 || Physical Examination [[image:check.gif]] || Physical Findings of the Patient; VS, Biometrics, Review of Systems ||  ||
 * T.CC.22 || Vital Signs - Vital Signs (R/N) including Pain Scale Assessment, Smoking Status [[image:check.gif]] || Patient's Vital Signs ; Heart rate, Resp Rate, Pulse Ox, Temp, B/P, Pain || Instructions regarding the capture of vital signs at points along the care plan and any special instructions regarding how to capture ||
 * T.CC.23 || Review of Systems [[image:check.gif]] || Functions of various body systems; Neuro, Derm, GI, GU, Cardiac, Pulmonary, MS, Repro, Nervous, Endocrine ||  ||
 * T.CC.25 || Diagnostic Results [[image:check.gif]] || Results and dates of Diagnostic Procedures || Corresponding results to the scheduled procedures and interventions. ||
 * T.CC.27 || Plan of Care - Plan of Treatment/Treatment Plan/Care Plan (R/N) - Covers the considerations that encompass a range of scopes and/or timeframe (could be a description of a single encounter or across multiple encounters) [[image:check.gif]] || Proposed interventions and procedures for patient || Goals. ||
 * ||  ||   || Results yet to be received and procedures to be followed up on. ||
 * ||  ||   || Active and scheduled interventions and orders (short term direct instructions - in the long run as validated by the patient and those contributed by the patient/caregiver). ||
 * || Education ||  || Patient education provided or needed. To included classes, educational sessions, printed materials. ||
 * || Diet/Fluid and Restrictions (R/N) ||  || Diet/Fluid: ||
 * ||  ||   || - All instructions that describe the expected diet. ||
 * ||  ||   || Restrictions: ||
 * ||  ||   || - List of limitations being placed on the diet ||
 * || Fluids Management (C/N) ||  || Fluids: ||
 * ||  ||   || - All instructions that describe the expected fluids and method of administration. ||
 * ||  ||   || Restrictions: ||
 * ||  ||   || - List of limitations being placed on fluids ||
 * ||  ||   || NOTES. Instructions may be more detailed if sent to another provider. ||
 * ||  ||   || Yes/No - has the plan been reviewed with the patient. ||
 * ||  ||   || Yes/No - has the plan been accepted by the patient, if no then how addressed ||
 * ||  ||   || Yes/No - has the patient assisted in the formulation of the plan of care ||
 * T.CC.28 || Family History [[image:check.gif]] || Dates with Disease Suffered, Age of Death, other genetic information ||  ||
 * T.CC.29 || Social History [[image:check.gif]] || Patient's beliefs, home life, social/risky habits, family life, work history ||  ||
 * T.CC.30 || Encounters || Current and historical encounters; dates ||  ||
 * T.CC.31 || Medical Equipment - includes assistive devices and is related to functional status [[image:check.gif]] || Implanted and External Medical Devices; Dates || List of devices and where the device is to be secured/prescribed/embedded. ||
 * ||  ||   || Duration of medical devices. ||
 * ||  ||   || History of devices (recalls, S/N, etc.). ||
 * T.CC.32 || Preoperative Diagnosis || Diagnosis ( Date) assigned to patient prior to surgery ||  ||
 * T.CC.33 || Postoperative Diagnosis || Diagnosis ( Date) assigned to patient after surgery ||  ||
 * T.CC.34 || Surgery Description [[image:check.gif]] || Particulars of Surgery (narrative) (images) ||  ||
 * T.CC.35 || Surgical Operation Note Findings || Clinically significant observations found during surgery ||  ||
 * T.CC.36 || Complications Section || Known risks or unidentified problems ||  ||
 * T.CC.37 || Operative Note Surgical Procedure || Date and Description of Procedure Performed ||  ||
 * ADDED || Electronic Links ||  || How to get to future results, summaries, etc. ||
 * ADDED || Functional Status (O/N) - [[image:check.gif]] ||  || Baseline, current and desired: ||
 * ||  ||   || Functional status ||
 * ||  ||   || End state/goal expressed/Projected change in functional status (will relate to the goals identified) ||
 * ADDED || Relevant Diagnostic Surgical Procedures/Clinical Reports and Relevant Diagnostic Test and Reports [[image:check.gif]] ||  ||   ||
 * ADDED || Patient Administrative Identifiers [[image:check.gif]] ||  ||   ||
 * ADDED || Relevant Diagnostic Surgical Procedures/Clinical Reports and Relevant Diagnostic Test and Reports [[image:check.gif]] ||  ||   ||
 * ADDED || Patient Administrative Identifiers [[image:check.gif]] ||  ||   ||


 * Attachments**


 * **Name** || **Size** || **Creator** || **Creation Date** || **Comment** ||
 * [|ONC_UCR_Scenario 2 Sub-WG meeting 03-22-11_Final.docx] || 31 kB || Amy Berk || Mar 23, 2011 14:23 ||  ||
 * [|ONC_UCR_Scenario 2 Sub-WG meeting 03-24-11_Final..docx] || 32 kB || Amy Berk || Mar 25, 2011 14:55 ||  ||
 * [|Scenario2Discharge.jpg] || 50 kB || Gregory L. Smith || Mar 29, 2011 13:22 ||  ||
 * [|Scenario2ClosedLoop.jpg] || 69 kB || Gregory L. Smith || Mar 29, 2011 13:22 ||  ||
 * [|Scenario2Sequence.jpg] || 31 kB || Gregory L. Smith || Mar 29, 2011 13:29 ||  ||
 * [|Scenario2SequenceClosedLoop.jpg] || 45 kB || Gregory L. Smith || Mar 29, 2011 13:30 ||  ||
 * [|ONC_ToC_Scenario 2_SWG_Agenda_032411_Final.docx] || 25 kB || Amy Berk || Mar 26, 2011 11:02 ||  ||
 * [|ONC_UCR_Scenario 2 Sub-WG meeting 03-25-11_Final..docx] || 32 kB || Amy Berk || Mar 26, 2011 11:01 ||  ||
 * [|ONC_ToC_Scenario 2_SWG_Agenda_032811_Final.docx] || 25 kB || Amy Berk || Mar 28, 2011 15:26 ||  ||
 * [|Scenario2DI.xlsx] || 19 kB || Gregory L. Smith || Mar 28, 2011 15:44 ||  ||
 * [|Dataset for Clinical Summary-aed.docx] || 30 kB || Gregory L. Smith || Mar 28, 2011 15:44 ||  ||
 * [|S2HospToProviderActionDiagram.mht] || 54 kB || Mayuri Patel || Mar 28, 2011 18:18 ||  ||
 * [|S2HospitalToProviderSequenceDiagram.mht] || 46 kB || Mayuri Patel || Mar 28, 2011 16:32 || Scenario2 -Sequence Diagram - Story 3 ||
 * [|S2HTPAD.png] || 29 kB || Mayuri Patel || Mar 29, 2011 08:28 ||  ||
 * [|ONC_UCR_Scenario 2 Sub-WG meeting 03-28-11_Final..docx] || 32 kB || Amy Berk || Mar 29, 2011 08:50 ||  ||
 * [|S2TOCDISCHARGEFROMHOSPTOPROVIDER.png] || 62 kB || Mayuri Patel || Mar 29, 2011 11:01 ||  ||
 * [|S2TOCDISCHARGEFROMHOSPITALTOPROVIDERSEQUENCEDIAGM.png] || 18 kB || Mayuri Patel || Mar 29, 2011 11:28 ||  ||
 * [|Scenario2DI_Fixes_After_Call_03292011.xlsx] || 15 kB || Gregory L. Smith || Mar 29, 2011 15:09 ||  ||
 * [|Scenario2DI_Fixes_03292011_Final.xlsx] || 15 kB || Gregory L. Smith || Mar 29, 2011 17:33 || Final worksheet on Discharge Instructions ||
 * [|Scenario2DI_Fixes_After_Call_03282011.xlsx] || 15 kB || Gregory L. Smith || Mar 29, 2011 13:39 ||  ||
 * [|ONC_UCR_Scenario 1 Sub-WG meeting 03-29-11_Final.docx] || 33 kB || Amy Berk || Mar 30, 2011 09:06 ||  ||
 * [|Scenario2CS.xlsx] || 15 kB || Gregory L. Smith || Mar 31, 2011 15:27 ||  ||
 * [|Scenario2DI_Fixes_03292011_2.xlsx] || 15 kB || Gregory L. Smith || Mar 29, 2011 15:11 ||  ||
 * [|Scenario2DS.xlsx] || 13 kB || Gregory L. Smith || Mar 31, 2011 15:27 ||  ||

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