Exporting a Patient's Clinical Data

To share a patient's clinical information with other providers, as well as with systems that store patient data, you can create a Continuity of Care Document (CCD) which contains or references portions of the patient’s summary information. After you have selected the clinical information you want to include, you encrypt and save your patient data using the Consolidated Clinical Document Architecture (CCDA).

When creating a CCD, two versions of the document are generated: an XML file (structured in CCDA) which allows for the import of patient information (as discrete data) in to an EHR system, and an HTML file. The HTML file can be viewed using any Internet browser; however, to view the XML file, you may have to make some adjustments to your computer settings, so that the XML file is launched by a specific application. For more information, see XML File Extension Settings.

The data type, as well as how the patient’s data arrived in Quanum^® Electronic Health Record (EHR), (manually entered, electronically received, or uploaded), determines whether these data are available as discrete data, referenced in the HTML file, or included as a separate file. The following section outlines where you can find the exported data, when it is available:

• Patient demographic information (including name, date of birth, sex, race, ethnicity, preferred language, contact information) displays in the HTML file and are available as discrete data in the XML file.

• Document and provider information (including document ID, document creation date, care team members, document author, and facility/provider contact information) displays in the HTML file and is available as discrete data in the XML file.

• Chief complaint and reason for visit, allergies and adverse reactions (active and inactive), problems (active and inactive), medications (including vaccinations and administered medications), procedures, encounter diagnosis, vital signs, cognitive status, functional status, social history, smoking status, pending tests (lab, radiology, and diagnostic), plan of care (including goals, goal source, goal instructions, future scheduled tests, future scheduled appointments, referred providers, patient health concerns and instructions, patient education, assessments and interventions/exclusions), patient clinical instructions, and reason for referral, display in the HTML file and are available as discrete data in the XML file.

• Lab, radiology, and diagnostic results that have been electronically received, display in the HTML file and are available as discrete data in the XML file.

• Clinical notes and other documents that have been electronically received, and encounter notes ( in progress and finalized) are listed in the HTML file as separate PDF files.

Note: In progress encounter notes can only be included in a CCD when the reason for disclosure is set to Provide Patient with Office Visit Summary. Otherwise, only finalized and signed encounter notes can be included.

• All uploaded documents (including lab, diagnostic, or radiology results, clinical notes, or other documents) are listed in the HTML file and exported in their original format.

Note: You must have the appropriate software on your system to view these (for example, Word to open a .doc file or Adobe Reader to open a .pdf file).

• Patient history is listed in the HTML file and exported as a PDF file. A single PDF file is created for all selected history items. Only procedures and smoking status are available as discrete data in the XML file.

Notes:

• CCDs generated by Quanum EHR are provided using CCDA.

• Users that are assigned the Phlebotomist or Clinical Lab Staff roles cannot export patient data.

Export a Patient's Clinical Data