The clinical summary will include a med list if you check the box to include it. It will print anything that is in the plan box. It will include immunizations given and immunizations and medications prescribed. If the patient needs specific instructions they can be added as well. It will include patient education handouts if the box is clicked just above the plan. If you use any EBM clinical support it documents that too. It would be pretty useless to list the 15 active diagnoses on a clinical summary sheet everytime you see a patient. I would say it would be exceptionally silly because when I go back I have a difficult time figuring out what I saw the patient for when some of the icd codes take the place of the diagnosis I actually gave the patient. I have asked my professional coder to please leave my diagnosis in the diagnosis area as well as the coded diagnoses so that I have some meaningful information for the care of the patient the next time I see them.
I don't think that the point is to meet all the criteria at this point. For example, you only need to give an electronic copy of the chart to half the patients who ask for it. I have done so for 100% at this point. Some of my summaries have been three or four pages long. Apparently I've started major consuming paper again. Staples will be happy.
