What is an Electronic Copy of Health Information?

In PowerReader, users are able to create an electronic copy of a patient's clinical information. A Continuity of Care Document (CCDA) is created in the Patient Info form and can be exported as an XML document and viewed as an XML/HTML document.

This document contains the results of any diagnostic tests performed on the patient, a list of patient's issues, medications prescribed for the patient and any allergies which the patient might have.

CCDA is exported through the Patient Registration form by clicking the Summary button.

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When you try to access the CCDA document for a patient, you have the option to select the required elements from the following menu bars:

• Demographics
• Health Information
• Encounter
• Care Plan

You can chose to select or de-select the elements that you want to be included in the Health Summary form. By default, all the elements are selected.

The CCDA document contains information from various sources. Apart from the patient information, the document contains a list of current allergies the patient has. The status of the allergy as well as the description of the allergy is also displayed. The second section of the document contains the problems the patient is facing.

The Medications section includes the current medications which have been prescribed to the patient. The Diagnosis Results section contains lab test results which have been entered in the Lab Results section of the Patient Info form. The Lab Test Results section contains the name of the lab result and the results of the test.

You can print or export the Health Summary (CCDA) form. By default, the CCDA document can be saved as an XML file. You can chose to view it in the XML format or as an HTML page.

Exporting a CCDA document

To export a CCDA document, perform the following:

1. Click the Export button on the Clinical Summary screen. The Export CCDA dialog box appears enabling you to save the CCDA document.
2. Choose the desired location to export the document. By default, you have an option to export it as an XML file.
3. Click Save. An information message box confirming the export is displayed.

Note: You can also export a CCDA document by right-clicking on a Patient Search record and selecting Export.

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This Meaningful Use feature is only available for RamSoft PowerServer with Meaningful Use license.