2020-04-29

Summative Clinical Documents: Connect Care to Netcare

The Alberta Netcare Portal provides a cradle-to-grave, read-only, aggregated view of information from multiple databases about key health events in an individual’s life; information that any health care provider may need in order to serve an individual. Key to this electronic health record (EHR) function is capture of key "summative" documents from a clinical information system (CIS) like Connect Care. 

Summative documents are high-value clinical notes that analyze diverse information sources and interpret these at healthcare milestones, such as outpatient visits or inpatient admissions. Included are discharge summaries, consultation reports, operative reports and transfer summaries.

While Connect Care has been sending summative documents to Netcare since launch, some gaps emerged. Summaries prepared by trainees (e.g., medical students, residents) were not transferring if bearing a "Cosign Needed" status. This departed from how such records were handled previously through provincial eScription. 

As of April 24, 2020, all summative Connect Care documents (in approved categories) transfer to Netcare, even when a final signature is pending. As previously, the document is released to facilitate clinical communication and gets re-released with any updates or when the responsible physician has fully signed-off. Work has begun to apply this same rule to any summative notes that missed transfer to Netcare between launch (November 3, 2019) and April 24, 2020.

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