ToC+Document+Types

include component="page" wikiName="siframework" page="TOC Header" The scope of the Transition of Care (ToC) Initiative is supported by four key clinical document types or constructs that contain specific patient information to facilitate the exchange of information in the event of a patient care transition:


 * **Discharge Summary:**The Discharge Summary is the clinical document used in the event that a patient is discharged from a healthcare provider, containing an overview of patient care information, such as demographic information, active reconciled medication list (with doses and sig), allergy list, problem list, and reason for admission. The document includes both a standard dataset and a discharge context relevant dataset, both of which are determined by the discharging provider organization in accordance with local policy, regulations and law. At discharge, the summary might include content for the Discharge Instruction as well as Discharge Summary.
 * **Sender:** Hospital EHR System
 * **Receiver:** PCP EHR System

> > >
 * **Discharge Instructions:**The Discharge Instructions contains the dataset relevant to the Discharge Summary context, which includes follow up/plan of care. The Discharge Instructions may be generic, patient specific, or disease specific depending upon the facility’s practices and the patient’s needs. The document includes data relevant to the following sections: Plan of care, allergies/adverse reactions/alerts, problems list, hospital discharge medications, advance directions, immunizations, and medical equipment. The document is given to the patient by their nurse or care manager at or a short time before physical discharge and a copy is sent to the patient’s PCP or Care Team. The patient’s acknowledgement that they have received, understood, and agreed to follow the Discharge Instructions, triggers the actual physical discharge.
 * **Sender:** Hospital EHR System
 * **Receiver:** PCP EHR System
 * **Consultation Summary:**The Consultation Summary is the document that contains information determined by the provider organization surrounding a consultation and consultation context-relevant data. When the PCP physician determines that the patient needs to be referred to a specialist, they prepare the Consultation Request within the EHR. It is addressed to the appropriate specialist, who in accordance with practice policies and workflow, reviews the document and orders any additional tests to be performed for the patient prior to the office visit. The Consultation summary should always include a basic set of information on the consultation that might also include content for the Clinical Instruction as well as the Consultation Summary. Consultation summary content examples include demographic information, active reconciled medication list (with doses and sig), allergy list, problem list and variable data relevant to the context of the request.
 * **Sender:** PCP EHR System
 * **Receiver:** Specialist EHR System
 * **Consultation Request Including Clinical Summary:**This information exchange would contain a standard set of data surrounding a consultation, and consultation context-relevant data, which is determined by the 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 Consultation Summary document. The Clinical Summary is an after-visit summary document that may contain variable data relevant to the context of the request. In addition, this information exchange also includes a PCP-selected referral-specific variable dataset. It can include any of the following items: 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 based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms. The Clinical Summary is addressed and sent to the PCP’s EHR as well as the patient’s PHR.
 * **Sender:** Hospital EHR System
 * **Receivers:** PCP EHR System, Patient Health Record

include component="page" wikiName="siframework" page="space.template.inc_contentleft_end"