Clinical Summaries (Outpatient/Ambulatory)
MU Objective Provide clinical summaries for patients for each office visit. 2014 Edition EHR Certification Criterion Ambulatory setting only – clinical summaries. Enable a user to provide clinical summaries to patients for each office visit that include, at a minimum, the following data elements: provider’s name and office contact information; date and location of visit; reason for visit; patient’s name; gender; race; ethnicity; date of birth; preferred language; smoking status; vital signs and any updates; problem list and any updates; medication list and any updates; medication allergy list and any updates; immunizations and/or medications administered during the visit; procedures performed during the visit; laboratory tests and values/results, including any tests and values/results pending; clinical instructions; care plan, including goals and instructions; recommended patient decision aids (if applicable to the visit); future scheduled tests; future appointments; and referrals to other providers. If the clinical summary is provided electronically, it must be: (i) Provided in human readable format; and (ii) Provided in a summary care record formatted according to the standard adopted at § 170.205(a)(3) with the following data elements expressed, where applicable, according to the specified standard(s): (A) Race and ethnicity. The standard specified in § 170.207(f); (B) Preferred language. The standard specified in § 170.207(j); (C) Smoking status. The standard specified in § 170.207(l); (D) Problems. At a minimum, the version of the standard specified in § 170.207(a)(3); (E) Encounter diagnoses. The standard specified in § 170.207(m); (F) Procedures. The standard specified in § 170.207(b)(2) or § 170.207(b)(3); (G) Laboratory test(s). At a minimum, the version of the standard specified in § 170.207(g); (H) Laboratory value(s)/result(s). The value(s)/results of the laboratory test(s) performed; and (I) Medications. At a minimum, the version of the standard specified in § 170.207(h). Standards § 170.205(a)(3) (Consolidated CDA); § 170.207(f) (OMB standards for the classification of federal data on race and ethnicity); § 170.207(j) (ISO 639-1:2002 (preferred language)); § 170.207(l) (smoking status types); § 170.207(a)(3) (SNOMED-CT® International Release January 2012); § 170.207(m) (ICD-10-CM); § 170.207(b)(2) (HCPCS and CPT-4) or § 170.207(b)(3) (ICD-10-PCS); § 170.207(g) (LOINC version 2.38); § 170.207(h) (RxNorm February 6, 2012 Release).