what is an integrated summary in writing research

For any problems that require the monitoring of clinical parameters over time, I enter those parameters directly across from (or near) their listed problem. The abbreviated plan section also shows that a one-time oral steroid burst (prednisone) was prescribed. For a few patients with complex problems, I must keep separate traditional (though organized) medication and problem lists when they exceed the space allotted on the integrated summary. “Expanded” problem list.

Copyright (c) 2003 Michael Stelman, MD. The integrated summary requires minimal data entry at each visit, and it simplifies progress note documentation. One of the common mistakes in writing a research is publishing an unclear and unpolished summary. It offers a template that can be altered to accommodate the work styles and preferences of any physician.

Integrated flowsheet values documenting bradycardia and restricted peak flow assist me in recognizing that atenolol is now contraindicated, for which I substitute hydroclorothiazide (HCTZ), and that albuterol is needed, as shown in the next column of the medication list. The summary section should present the key points that resonated from your review of each pertinent area presented. When sending patients to consultants or the emergency room, or when giving records to patients who are moving away, I often copy just the integrated summary. Problem list is updated accordingly.

Keys to High-Quality, Low-Cost Care: Empanelment, Attribution, and Risk Stratification

This might span six weeks in a patient with severe hypertension whose medication is being aggressively titrated or six years in a healthy patient getting yearly mammograms. The integrated flow sheet shows the home glucometer readings are suboptimal in response to the glyburide dose recorded above, and an augmented twice-daily dose is recorded in the next column. The summary is integrated in that it includes data on one page from multiple (and now unnecessary) parts of a traditionally organized chart. On January 7, 2015 January 6, 2015 By E. Mack In Uncategorized . I also document last menstrual period and lactation here to remind me of drug contraindications in patients who are at risk of conception or who are breast-feeding. Having a single page facilitates compulsively keeping my lists of problems, medications, lab results and screening tests due up-to-date.
“Organized” medication list.

The atenolol she reports taking is entered into the initial column of the medication list. Patient demographic data is recorded across the top of the integrated summary.

I use default conventions for “mg” and “qd” when units and frequency are not specified to further minimize data entry.

Grouping like agents (and leaving blanks above and below to add future agents for other systems) makes it easier to associate groups of drugs to a corresponding problem and choose when to titrate existing drugs or add a new agent. Finally, the demographic entry “no insurance” prompts me to encourage her to apply for insurance to cover future expenses. Quanticate's Medical Writing Team have summarized tips for the preparation of comprehensive, well-written, and focused integrated summary documentation..

O: Suboptimal home and clinic glucometer readings and glycohemoglobin levels, improved compensated blood-pressure readings and normal monitoring liver function test results are recorded on IS. / Integrating Research into Your Writing. UNA Center for Writing Excellence 1 Source integration is often an essential part of academic writing. The use of an integrated summary considerably reduces the time needed to address problems at every stage of the assessment.

The top panel on the right leaves room for chronic medications to be entered.
The medical record is an important part of patient care, yet too often it is difficult to use. Patient notes a cough since starting captopril.

The problem list adds that diabetes mellitus (DM) has been diagnosed. It also shows that prophylactic aspirin has been recommended now that the patient has other CAD risk factors with DM. The Integrated Summary: A Documentation Tool to Improve Patient Care. More importantly, however, it is integrated in that the relationships between problems, medications and measured flowsheet parameter results are evident on a single page, and their changes (compensated or decompensated, improving or progressing) are readily apparent over time.

See, How it works – template layout and integration, Ten EHR Strategies for Efficient Documentation, Making Family Practice Doable in Everyday Life. The integrated summary simplifies the progress note; it does not duplicate it. In writing a research paper it is needed to have the skill of summarizing more than two sources.

Hospital admission lab results are added to the preceding column, and colons mark the pending results of tests ordered today. It takes only a few seconds during my interview to record today’s data into the flow sheet, write any medication adjustments into the medication list and record an abbreviated plan. Worst practices for producing an integrated summary. Integrated Summary of Effectiveness Guidance for Industry U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research (CDER) Her problem of smoking is expanded to document the intervention of cessation counseling.

Use empanelment and risk stratification to better understand where to expend your practice's care management and care coordination resources.

When This allows the physician to follow, for example, the response of the glycohemoglobin (HbA1c) or blood pressure as a function of the number of drugs and their dosages. Being too brief; Excluding data that do not support the effectiveness conclusions

Plan.

The current increase in hesitancy about the safety and efficacy of vaccines has created an environment that calls for physicians’ urgent commitment to discussing the evidence-based benefits of vaccination with pregnant women. This easy-to-use template enables you to see the full context of a patient’s health on a single page.

To save space and time, I enter only changes to medications, rather than rewriting the prescription information for each visit.

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