Clinical summaries (MU2))

MU Requirements

Per ONC

Taken from ONC Final Rule:File:2014 Edition Cert Federal Register.pdf

(2) Ambulatory setting only – clinical summary. (i) Create. Enable a user to create a clinical
summary for a patient in human readable format and formatted according to the standards
adopted at § 170.205(a)(3).
(ii) Customization. Enable a user to customize the data included in the clinical summary.
(iii) Minimum data from which to select. EHR technology must permit a user to select, at a
minimum, the following data when creating a clinical summary:
(A) Common MU Data Set (which, for the human readable version, should be in their
English representation if they associate with a vocabulary/code set)
(B) The provider’s name and office contact information; date and location of visit; reason
for visit; immunizations and/or medications administered during the visit; diagnostic tests
pending; clinical instructions; future appointments; referrals to other providers; future
scheduled tests; and recommended patient decision aids.

Per ONC/NIST Final Test Methods

See here: http://www.healthit.gov/policy-researchers-implementers/2014-edition-final-test-method

Status

• This item will be supported by the ZH Healthcare Care Coordination Module: http://sourceforge.net/p/zhopenemr/wiki/Care%20Coordination%20Module/

Owner

ZH Healthcare

Links

• OpenEMR Certification Stage II Meaningful Use Main Project Page
• Patient Clinical Summaries wiki page for stage I certification