Patient Visit Summaries: what your doctor writes up after your appointments with him

Your appointment with your doctor is over. You both smile and shake hands, he says he looks forward to seeing you the next time, and you exit the exam room and head for the checkout station.

At that point maybe you aren't thinking all that much more about the appointment you just had, but it's likely your doctor is. He's heading towards his office to sit down at his desktop and type up and save a summary of what the two of you just talked about and did at the appointment.

"Patient Visit Summary" (PVS) seems to be a common online term I found for what he will type up and save (although there are other names for it, such as After Visit Summary, or simply Clinical Summary), and it will obviously be a short-but-complete write-up of the important points covered and procedures that were done. When completed, it will most likely be added to an online folder with all of the other patient visit summaries that your doctor has typed up for you for your previous appointments.

So just how is this patient visit summary prepared? Is there a medical standard for doing it? Is certain information required to be in it? Or can it be just the doctor's more-or-less freeform personal notes on what he felt were the important matters of the appointment?

After a little websearching, this seems to be the most relevant government guideline I found, which also provides a link to a more detailed document:

https://www.healthit.gov/resource/providing-clinical-summaries-patients-after-each-office-visit-technical-guide

And from another relevant document, these points are recommended for inclusion:

The PVS should include:

1. information and instructions containing the patient name, provider’s office contact information, date, location of visit.

2. an updated medication list, updated vitals, reason(s) for visit.

3. instructions based on clinical discussions that took place during the office visit.

4. any updates to a problem list, immunizations or medications administered during visit.

5. summary of topics covered/considered during visit.

6. time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled.

7. list of other appointments and tests that the patient needs to schedule, with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.

from:

https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/13_clinical_summaries.pdf#:~:text=clinical%20summary%20%e2%80%93%20an%20after-visit%20summary%20that%20provides,received%20before%2024%20hours%20after%20visit%29%2c%20and%20symptoms.

But I also found that the above are presented as guidelines, and not as mandatory, so it seems that the note-recording doctor does have some liberty in writing up his notes.

Another recommendation I noted stressed that the PVS needs to be as close to 100% objective as possible, with any subjective observations on the part of the doctor minimized or preferably absent. Added was that the PVS should be written by the doctor with the thought that the patient might actually be reading it someday, certainly possible, with patient access to medical records much supported these days, and there should be nothing in the PVS that might lead to doctor-patient misunderstanding. "I think this patient is a total hypochondriac!" is an observation probably best left out of a PVS.

Incidentally, my own general health care clinic here in Gainesville:

https://ufhealth.org/uf-health-family-medicine-main

does allow access to patients' past PVS reports on their personal account page. I have looked at mine, as they are posted and accessible a day or two following an appointment, and I have been satisfied that my family doctor has been objective and thorough in writing them.

Do any of you have access to your own PVS reports, if you are seen at a facility that allows such access, presumably online? If unsure, you might want to check and see if earlier PVS write-ups of your appointments are available to you.

If access is available, it just might be a good idea to call up and review what your doctor wrote up about one or more of your past appointments with him. To confirm that you and he are on the same page about things, and perhaps to remind yourself of something that was said or done at a past appointment that may have slipped your mind, but is recorded there in the PVS for you to see.

Another tool in our relationship with our doctor, and one we might get into the habit of regularly reviewing, if it is possible for us to do so.

I will second what Jack said. I don't bother to read visit summaries anymore. For ALL of my doctors the notes seemed to be canned -- usually just a copy of the previous note. Conversations that never took place and omissions of conversations that did take place. I think the notes are mainly for CYA purposes.

I hear you my brothers ...

My oncologist types up the summary, right as we are wrapping things up.

As I check in, my care nurse types in updated data on my vitals. I'm working on dropping some "winter weight" and I am able to look back and track my progress ~ at present, I have dropped 20 pounds since February.

My lab work results from the past 10 years are also on my online patient account. It's interesting to occasionally look back and see the impact that ZYTIGA, chemotherapy, and radiation had.

One thing to add ~ I have my oncologist add bits of information that I feel is important to note in my record, for future reference.

We note dates of vaccine boosters, PROLIA injections, dates when treatments were given ~ things that I occasionally look up.

At the top of my appointment summaries, it is stated that my case is co-managed with Dr. Kwon at Mayo Clinic. When I have visited Mayo, they have instant access to my summaries.

Some time ago, my main oncologist moved away to a distant state. I will say his summaries were nicely detailed.

When my newer oncologist took over my case, he had memorized the salient points of my case, in remarkable ways, for our first appointment.

That made a huge impression on me. My newer oncologist has carried on the tradition of adding nicely detailed notes. I really value my doctor. He looks after me like a brother.

Some experiences to share today ~

CYCLONE ~ # Iowa State University

All interesting points ...

At the large Mayo Clinic in Rochester, Minnesota, I have noticed Dr. Kwon (a friend of mine famously called him "The Mighty Kwon" ) records oral statements, in between consultations, which are then transcribed into detailed patient summaries by his assistants.

At my local clinic, where I see my oncologist, there's a small team of very hard-working and very dedicated oncologists.

I see the seemingly never-ending "flurry" of patients they see, each time I am there, every month. It reminds me of the parent-teacher conference nights I have hosted for years in my classroom, seeing one set of parents right after another.

That schedule is almost dizzying ... so, I an mindful of that when I see my oncologist.

When one of the oncologists at my treatment center is gone or on vacation, the rest of them cover those bases. Hectic, without a doubt ...

As retirements occur, they cover those bases, too ~ until a new oncologist joins the team.

This is when those patient summaries can become critical and vital ... as was the case when my original oncologist moved to a different state, to be reunited with his family from Kenya.

My new oncologist did a REMARKABLE job of "jumping in" and mastering the details of my treatment history from past summary notes.

That did not go unnoticed by me & I knew my new oncologist was the perfect doctor for me, going forward.

CYCLONE ~ # Iowa State University

Don’t sweat it guys, when AI kicks in I am sure that it will be more verbose than the docs.