Transition of Care

You are here:
← All Topics

1. INTRODUCTION

1.1 ABOUT THE FEATURE

Transitional care refers to the coordination and continuity of health care during a

movement from one healthcare setting to either another or to home, called care

transition, between health care practitioners and settings as the patient’s condition and

care needs change during the course of a chronic or acute illness. Transition of care in PertexaIQ

supports C-CDA (Consolidated-Clinical Document Architecture) format.

C-CDA

The HL7 Consolidated CDA is an implementation guide which specifies a library of templates and

prescribes their use for a set of specific document types.

CDA

The HL7 Clinical Document Architecture (CDA) is a document markup standard that specifies the

structure and semantics of “clinical documents” for the purpose of exchange.

It contains following tasks under transition of care.

1. Visit Summary/Office visit

2. Patient Summary/Clinical Summary

3. Reconciliation

4. Data portability

1.1.1 VISIT SUMMARY

Office visits include separate, billable encounters that result from evaluation and management services

provided to the patient. It records single encounter/visit data.

User need to follow the following steps to generate visit summary from Radekal:

1. Login to Docpad

2. (add patient, if needed)Open Progress Note of a Patient

3. Add demographic, medications, allergies, vitals, immunizations, social history, problems,

procedures, diagnosis, lab result and chief complaints.

4. Go to sign note and sign note. On sign note page there is download visit summary button to

download CDA visit summary document if user want to.

5. After signing note, open same patient’s past note, go to transition of care tab. Over there you found

one clinical document generated on sign note action.

6. User can view visit summary, download or send to any provider through provider direct

address.

1.1.2 PATIENT SUMMARY/CLINICAL SUMMARY

An after-visit summary that provides a patient with relevant and actionable information and instructions

containing the 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.

User need to follow the following steps to generate Patient summary from Radekal:

1. Login to Docpad

2. Open progress note of old patient have multiple visit/encounter.

3. Go to Transition of care tab, click on patient CDA tab and click on +New CDA.

4. On the same page patient summary is visible with all the details.

5. User can view, download and send patient summary.

1.1.3 RECONCILIATION

Reconciliation enable a user to reconcile the data that represent a patient's

active medication list, medication allergy list, and problem list as follows. For

each list type: (A) Simultaneously display (i.e., in a single view) the data from at

least two sources in a manner that allows a user to view the data and their attributes, which must

include, at a minimum, the source and last modification date. (B) Enable a user to create a single

reconciled list of each of the following: medications; medication allergies; and problems. (C) Enable a

user to review and validate the accuracy of a final set of data.

User needs to follow the following steps to generate Patient summary from Radekal:

1. Login to Record

2. Click on Create Documents

3. Select CDA XML file from inbox and move right side.

4. Select Document type, Patient, Physician, Subject, Date and click on Send to Physician.

(Note: CDA document must be match with the selected patient.)

5. Login to Docpad

6. Open Progress note.

7. Go to Transition of care tab, click on Incoming CDA tab.

8. Select files using check box and click on Reconcile.

9. On this page user can see existing patient data as well as incoming data and

also user can compare.

10. Select findings from each section to merge with patient data and click on

merge.

11. On the next screen you can see the merged data with status. Click on confirm

merge to finally merge data with patient data.

Data portability enable a user to electronically create a set of export summaries for all

patients in EHR technology formatted according to the standard adopted at §170.205(a)

(3) that represents the most current clinical information about each patient and includes,

at a minimum.

User need to follow the following steps to generate Patient summary from Radekal:

1. Login to Docpad

2. Click on Patient Summary link

3. Select My patient/All Patient and search patient by name.

4. Select patients and click on Download to download selected patients Patient Summary.