Editing Signed Notes

Summative Documentation

When documenting at transitions of care, or at milestone events during an encounter, "summative" documentation is used to capture a snapshot of a patient's status. Summative documentation gathers information pertinent to an encounter, organizes observations, exposes meaning and offers a plan keyed to goals.

Summative Documentation Types

The following types of summative documentation are subject to AHS provincial standards (with expectations for style, headings and information ordering expressed in standard templates).

• Emergency Department Provider Note (summary of ED encounter)

• Admitting History and Physical

• Labour and Delivery Report

• Operative Report

• Consultation Report

• Discharge Summary

• Deceased Note (unique template applied within the Discharge Summary note type)

• Inter-facility Transfer Note (unique template applied within the Discharge Summary note type)

Note templates

Smartphrases have been developed to ensure summative notes align with AHS provincial standards. Below are the "dot phrases" that can be used to apply the note template for each type of note.

H&P Admission Note .ahsipbasicAdmit

Consult Note .ahsipbasicConsult

Discharge Summary .ahsipbasicDCSummary

Progress Note .ahsipbasicProgress

Upload to Netcare & PCP

Inpatient and Emergency Department summative notes are automatically uploaded to Netcare and sent to the patient's Primary Care Provider (PCP) when signed by the authoring trainee. 

• This routing takes place when the note is signed by the authoring trainee, even if a co-signature has not yet been completed.

• Routing to the PCP typically involves the note going to their community Electronic Medical Record (EMR)

• Where a PCP does not use an EMR it may be faxed to their clinic. 

Addending a Signed Note

Each time a note is edited, or Addended, then signed, the revised note is routed to Netcare and the PCP. 

There have been instances of community physicians receiving multiple versions of the same note.

• In Netcare the new note overwrites the old note

• For community EMR the new note does not overwrite, it is sent as a new message

• When sent by fax the entire note will be received and printed out 

Save or Pend vs Sign

When a summative note is Saved or Pended, it is visible to all in Connect Care but will not be uploaded to Netcare. 

• When authoring a note consider saving the note until you are certain that no additional changes will be required, then Sign the note.

Edit and Save

When editing, consider saving it until you are certain no additional changes are required, then Sign the note.