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. 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

Important Links