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Tuesday, August 31, 2010

What's the Diff?

Dan wants to know what the difference between a C32, a Patient Summary, and a Summarization of Episode document is.  This is a really GOOD question.

So, let's take these in reverse order. 

A Summarization of Episode Document (or Note as it appears in LOINC) is a document that summarizes an episode of care for a patient.  That brings in two questions:
What is a summary, and what is an episode?
Wictionary gives us "concise, brief or presented in a condensed form" for summary, and "incident or action standing out by itself, but more or less connected with a complete series of events." for episode.  These are good enough to explain what a summary of episode note is.  It is a concise or brief note describing an incident in the care of a patient.  It isn't every detail, or even a life history, though it can be and has been stretched to cover both these extremes.

A Patient Summary is any of a variety of clinical notes which provides a summary of information about a patient.  It may involve an episode of care or not.  Patient summaries include History and Physical Notes, Consult Notes, Summary of Episode Notes, Discharge Summaries, Transfer Summaries, and Progress Notes.  The key point is that it contain a summary, and not every last detail.

The ANSI/HITSP C32 is a Patient Summary that uses the HL7 Continuity of Care Implementation Guide.  That guide specifies that the document type be coded as a "Summary of Episode" note, that being the closest thing in LOINC to what the intent of the CCR was when it was harmonized with CDA through the CCD.  So, the C32 is a Patient Summary, and is a Summarization of Episode Note (or Document).  It isn't the only way to summarize an episode (a Discharge summary is a very specific summarization of an inpatient episode of care), but in the US, under meaningful use, it is something that will be needed for just about every encounter.