PS-CA:BC Patient Summary Overview
A patient summary is a point in time health record extract, comprised of a concise and clinically relevant collection of information (retrospective, concurrent, prospective), including the minimum necessary and sufficient data to inform a patient's treatment at the point of care (ISO/TR 12773-1:2009 Business Requirements for Health Summary Records). Patient summaries can help improve:
- Patient safety through the reduction of preventable harm caused by clinical errors and misjudgments
- Coordination of care and health outcomes during the patient's journey across health services
- Patient experience and satisfaction with care provided
- Clinical workflow efficiencies and provider experience
The patient summary will contain a validated human-readable document in a standardized style and format in alignment with national standards that incorporates a mix of free-text and discrete values from a variety of sources. This guide leverages national standard (i.e. PS-CA to ensure consistent data representation across jurisdictions, with additional BC-specific notes documented within the IG. A patient summary:
- Is concise and minimal
- Is location/care-setting independent (i.e., patient summary information is not specific to location/service it is created in or accessed in)
- Is specialty-agnostic (i.e., information in the patient summary is not filtered for a specialty)
- Is condition-independent (i.e., the patient summary is not specific to a particular condition)
- Is a consistent and easy way for healthcare practitioners to see their patients’ most important health facts at a specific point in time.
- Reduces risks to patient safety by providing essential health care information to the health care practitioners who deliver care to a patient.
- Reduces the need for patients (and their caregivers) to answer the same questions by different healthcare practitioners.
- Improves the patient and practitioner experience by reducing the fragmented approach to accessing health information.
A patient summary is not:
- An exhaustive, comprehensive, longitudinal patient record
- A billing record (transaction level)
- An encounter-specific record
Clinical uses of patient summaries may include:
- Medical Emergencies
- Provider unfamiliar with patient at the point of care
- Coordination/Transitions of care