Design
> Document Taxonomy
Release Information
| Project: | EGADSS |
|---|---|
| Internal Release Number: | $Revision:
1.11 $ |
| Related Documents: | Design > Design
Document Patient Summary schema Patient Summary description Results schema Results schema documentation |
Patient Summary
The "Patient Summary” document is a structured CDA document that conforms to the predefined Patient Summary schema. The document contains a subset of patient data that is sent from an EMR to EGADSS, typically in response to a clinical event such as a patient encounter. The “Patient Summary” is essentially a cumulative patient profile as typically recorded in a patient’s record – traditionally on the inside cover of the patient’s paper chart. Note that patient data must be coded in order for EGADSS to automatically interpret the document.The "Patient Summary" document is defined as a minimum collection of patient data (the core data set) and various extensions. The core data set sections are required to be present in the "Patient Summary", while the extension sections are only required when explicitly requested by the EGADSS from an EMR.
The “Patient Summary” includes the following clinical components (which are described in more detail in the Patient Summary description):
- Core data set sections:
- Patient Demographics
- Active Medical Problems
- Past Medical History
- Surgical History
- Medications
- Allergies and Adverse Reactions
- Family History
- Immunizations
- Social History
- Extension sections:
- Labs
Results
The "Results" document is a structured CDA document that is generated by EGADSS and conforms to the predefined Results schema. The "Results" document consists of two parts: clinical recommendations and a request for additional patient information.Clinical Recommendations
This part of the document contains all recommendations triggered by EGADSS guidelines for a given Patient Summary.
A guideline may produce a recommendation if it is (a) triggered and (b) results in an action being required. Guidelines that are not triggered or that are triggered but do not result in an action (e.g. Patient over 50 but who had colon CA screening within the past year; thus no action needed) will not produce a recommendation that is shown to the clinician. Given the atomic nature of EGADSS guidelines written in Arden MLMs, currently it is assumed that a guideline will only produce a single recommendation for a given patient.
Each recommendation is structured. The majority of the recommendations are structured free text, but this allows us to move forward with a more active system in the future if we allow for structure and codes.
The following is a list of clinical elements of a single structured recommendation that were defined for EGADSS. For the detailed description of these elements see Clinical Recommendations document.
- Guideline Title
- Guideline Encoding Version
- Guideline Citations
- Guideline Domain Expert
- Guideline Encoder
- Guideline Encoding Institution
- Last Encoded Guideline
Modification
- Recommendation Subject
- Recommendation Instruction
- Recommendation Conclusion
- Recommendation Urgency
Request for Additional Patient Information
The "Results" document also may contain any number of requests for additional patient information. Based on such requests, an EMR may choose to resend the "Patient Summary" with the additional patient information in order to obtain a potentially more extensive set of recommendations from EGADSS. Note that in the current version of EGADSS, Request for Additional Patient Information is not implemented yet.