After Visit Summary

DEFINITION

What Is an After-visit Summary?

In the healthcare industry, an after-visit summary (AVS) is a report received by a patient following a medical visit. It provides a record and a reminder of everything discussed during the visit, including personal and medical information, lists of medications and allergies, diagnoses, prescription orders, and follow-up appointments.

The after-visit summary is a helpful tool both for helping patients and their caretakers stay up to speed on their current medical status, and for helping healthcare providers keep accurate and up-to-date records of each patient’s treatments, needs, and concerns.

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What is the purpose of the after-visit summary?

The goal of an after-visit summary is to give patients an easily referenced summary of their current health and their options for future care. The four main functions of an AVS can be summed up as:

  1. Educating patients
    An AVS provides key educational guidance to patients and their caregivers and helps them understand their health status and options, including medications and future visits.
  2. Helping with memory
    Medical information can be complex and confusing, especially for people in the middle of a healthcare issue. An AVS is an easy reference sheet to help with recall.
  3. Assisting with self-management
    A visit to a healthcare professional often comes with homework. Referring to an AVS helps patients stay on schedule and up to date with managing their own care.
  4. Maintaining a record
    Being able to quickly refer to an AVS for vital information helps to improve a patient’s electronic health records (EHR) with easily accessible, high-quality information.

Who issues medical after-visit summaries?

At the conclusion of a patient visit, the clinician will typically generate and issue a patient-specific AVS. This may be delivered electronically or as a paper document, depending on the patient’s preference. Along with information about prescriptions, upcoming appointments, and possible diagnoses, a clinician or doctor may also make personal notes and recommendations intended to help a patient more easily understand their treatment options.

An AVS may be issued by clinicians in any area of healthcare, including primary care physicians, specialists, dentists and orthodontists, physical therapists, and many others. The specifics of what is included in an after-visit summary will vary depending on the type of care being provided but most of the basic details will be similar across all segments.

What is the in-clinic timeline of an after-visit summary?

Creating an after-visit summary usually follows a set process to ensure that each AVS is created as consistently, accurately, and efficiently as possible. Exact details may vary depending on the type of healthcare being provided, the preferences of the clinician, and the needs of the patient, but the steps followed will generally look something like this:

  • Clinical assistant informs the healthcare provider that a patient is ready to be seen
  • Healthcare provider reviews the patient’s chart and greets the patient
  • Provider asks the patient questions to establish expectations for the visit
  • Provider opens after-visit summary template and enters information relevant to the established agenda
  • Provider checks for any pending orders and updates lists of medications and patient concerns
  • Provider enters details on:
      •  Patient’s diagnosis
      • Explanation of what that diagnosis means
      • Explanation of what to do next
  • Provider provides patient with finished AVS via email, text, physical document or other patient preference

What Information Do After-visit Aummaries Include?

Depending on the type of visit, the provider’s discretion, and the patient’s concerns, an AVS may include many different kinds of information. The following items, however, are generally considered to be after-visit summary requirements regardless of any other factors. A thorough AVS should include:

  • Patient identification
    Name, date, provider’s name, primary care physician’s name
  • Comments from the provider
    “What you have, what it means, and what to do”
  • Patient vital signs
    Weight, BMI, pulse, blood pressure
  • Diagnoses
    Patient’s reason for the visit and provider’s diagnoses for any related or incidental issues
  • Tests and treatments ordered
    Tests, referrals, and medication orders, reorders, and refills
  • Test results
    Results of laboratory, imaging, and ECG tests, as well as any other results available by visit’s end
  • List of medications
    All medications prescribed to a patient, as well as the date when the list was last updated
  • List of medical allergies
    All known allergies as well as the date of the patient’s last allergy review
  • List of known patient problems
    All chronic or acute medical problems as well as the date of their last review
  • Monitoring of chronic conditions
    All monitoring activities as well as results and dates of each activity
  • Health maintenance (HM) information

All preventive health measures being taken, as well as plans and orders for needed interventions

After-visit Summary Example

We’ve included an example of a typical AVS document. Note that it provides a brief but thorough record of all of the vital details about a patient visit. The ideal AVS is quick and easy for a provider to complete on each visit, while also being direct and understandable for the patient.

Best Practices in Issuing After-visit Summaries

As with most healthcare topics, there is no one right way to approach the after-visit summary, especially since it is often a document of deeply personal details and preferences. Even so, there are some best practices to keep in mind when crafting an AVS to ensure that it reflects an effective collaboration between a patient and a provider. As a rule, healthcare providers should be sure to:

  • Define a clear agenda for the visit – Delivering a useful AVS is more challenging if the patient and provider aren’t on the same page. At the very beginning of the visit, the patient and provider should have a conversation about expectations. What does the patient want to learn or talk about in this visit? What does the provider want to discuss? How much time will be dedicated to the visit? Laying out a clear agenda for the visit early on helps to ensure that the information included in the AVS is helpful to the patient’s knowledge and future healthcare plans.
  • Designate times to collect all AVS information – A good amount of information goes into crafting a useful after-visit summary, and fitting all of that data into a patient visit can be difficult without a specific plan. Establishing a routine of asking for certain information at certain points in the visit makes it easier for a provider to remember to ask for all of the pertinent details without having to scramble to fit them all in at the end of the visit.
  • Develop a framework for individualized comments – Healthcare appointments often move quickly, and providers have a lot of patients to see on any given day. That makes it prohibitive to provide personalized comments on every element of an after-visit summary. Providers can save time without losing meaning by condensing individualized comments within the scope of “What do you have?” “What does that mean?” and “What should you do about it?”

Printing the AVS

While many patients who feel more comfortable with technology may prefer to receive their AVS via a patient portal or other electronic media, this is one area where physical documents will often be the preferred option. Printing an after-visit summary on paper gives the patient an easy-to-reference overview of all of the most important information about their visit, an especially helpful feature for patients who are less tech-savvy. A paper AVS also makes it easier for a provider to review a visit with the patient and highlight any specific concerns or areas of focus.

Of course, in an era of documentation that is quickly moving away from paper documents, managing and tracking physical after-visit summaries can be a time-consuming task. That’s why healthcare organizations are increasingly turning to document automation solutions to ensure a fast, reliable AVS experience for all patients, whether they prefer their summary delivered digitally or on paper.

Simplify AVS Printing with Document Automation Software

Automating your organization’s document production is the surest way to know that patients are receiving AVS documents that are consistent, complete, and correct. Document automation software covers the entire process of creating and delivering an AVS, from the initial setup to the final distribution. MHC document automation solutions provide:

  • Efficient AVS Templates
    MHC automation makes it easy to design an after-visit summary template that matches your organization’s design style, including logos and branding assets. Our document rendering uses APIs to pull data from multiple sources, allowing you to make personalizations and adjustments as needed.
  • Simplified AVS Printing
    An automated system allows providers to instantly print after-visit summaries remotely or in-person with on-demand document generation. If your organization also requires high-volume print jobs, navigating between on-demand and batch printing is quick and easy.
  • Omnichannel AVS Delivery
    For patients who prefer electronic summaries, MHC automation software works with a wide range of communications channels, allowing you to easily distribute an AVS via email, SMS text messaging, fax, or any channel your patient prefers.
  • Storing Digital AVS Long-Term Safely
    MHC automation allows your practice to store all of your document templates, logos, graphics, and other assets in a single, easy-to-access location. That makes it simple to make changes and adjustments while also keeping all of your data and assets secure.

Ready to learn more about the ways document automation software can help streamline the after-visit summary process, improve accuracy and consistency, and provide a better patient experience overall? Contact MHC today to schedule a demonstration, and don’t forget to download our document automation buyer’s guide for more insights!

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