Summary Note for every online consultation

Summary Note is a mandate for all online consultations as per the Telemedicine Practice guidelines. Here’s all you need to know:

What is a Summary Note?

A Summary Note is a digital record of your findings during the consultation, such as provisional diagnosis, along with any advice you may have for the patient, which is to be noted under General Advice.

You may additionally, depending on the requirements of the consultation, prescribe a medicine or lab test as per your discretion. A digital Summary Note is different from typing the same over chat or explaining it over the call and has to be a proper digital document generated on the platform with necessary communication headers and footers.

Here’s a sample Summary Note for your reference.

Why is it important to provide a Summary Note for each online consultation?

As per the Telemedicine Practice guidelines, a digital record of the consultation in the form of a summary note is now mandatory for every online consultation. This is required even in cases where there’s no medicine or test prescribed by you. The consultation without a Summary Note might be treated as incomplete due to the high degree of non-compliance risks attached to it, and the same might reflect in the payments as a cancelled transaction.

How to issue a Summary Note?

The Summary Note can be issued from the Practo Pro app in the Summary and Rx module. Some of the sections where data is available will be pre-filled and the remaining can be filled by the doctor as applicable for the consultation. This can then be sent out to the patient as a PDF file on the consultation chat window. It will be auto-generated from the app by clicking ‘Submit’. It may or may not include a medicine or lab test prescription at all times.

Frequently Asked Questions(FAQs):

1. What happens if I don’t provide a Summary Note?
   1. A summary note is an essential document that has the record between the doctor and patient, of what was discussed as an outcome of the consultation. A summary note not being shared may lead to the consultation being treated as incomplete and the consultation being treated as cancelled or void, thereby not being eligible for a payment associated with it.

2. How is Summary Note different from prescription?
   1. A Summary Note is generated in the Summary and Rx module. A prescription may additionally include a medicine or lab test as per the discretion of the doctor. A plain Summary Note may be as simple as just the provisional diagnosis and general advice documented as a system-generated PDF sent to the patient at the end of the consultation.

3. Why is it required even in cases where no test or medicine is prescribed?
   1. It is required that the outcome of every consultation be documented on a valid digital note summarising the findings made during the consultation by the doctor. Even if there is no medicine or test to be prescribed, the doctor must still document the discussion on a Summary Note and share it with the patient at the end of each consultation.

4. Why will the consultation be treated incomplete or cancelled without a Summary Note?
   1. A consultation without a Summary Note is a non-compliant consultation as per the Telemedicine Practice Guidelines and is hence treated as incomplete and high non-compliance risk. This helps us and doctor partners adhere to the guidelines and be compliant with the best practices.

5. I am not having access to the Summary Note module. Will my consultation be treated as cancelled
   1. We have currently blocked access to the Summary Note for Allied Health Professionals. We are in the process of getting this changed and soon every provider of consultations on our platform should have access to the summary note module. Once the access is enabled, we would start treating the consultations as mandatory to have a Summary Note. Till then, we would ensure that the consultations are not incorrectly getting deemed as cancelled.

6. I sometimes find that a certain medicine is not available in the Rx module and hence am not able to share across a prescription. What should I do?
   1. In such cases, we recommend that you write the medicine in the General Advice section of the module. Subsequently, you can write to us and we will ensure that the medicine gets added to the list of medicines that can be prescribed from the module.
   2. We have a team that is actively maintaining the list of medicines that are deemed available for being prescribed. This takes into account changes to medicines that keep happening with time, new medicines coming into the market and older ones being discontinued. While we do our best to keep updated with the latest data, there may be occasional cases where some medicines might not come in our update process. In such cases, we request that you can help us to keep our data updated by dropping us an email to support@practo.com and our team will do the needful.

7. I am facing issues in sending the Summary Note to the patient. Will you still treat the consultation as voided?
   1. We understand as a tech platform that there may occasionally be some glitches that come in the way of giving a Summary Note. In such cases, you may raise a concern to our team and we will make a due note that there was a genuine tech issue and hence we would make a case-to-case consideration as required against the payment reconciliation.This however is only a rare exception and not a norm and will be against known issues only.

8. I am currently using my own prescription pad to give a Summary Note. Do I need to move to the Practo Pro app module to start sharing a Summary Note?
   1. We recommend that the Summary Note module should be given on the Practo module instead of an image of the prescription pad.
      1. There are several benefits to using the Practo module – it is faster, more detailed with the various sections to capture information separately, and is more compliant in terms of having necessary information required to be presented in an e-prescription. 
      2. The final output is in an easy to consume PDF format that the patient can access at any time – the prescription pad may often end up being blurred, low-resolution or difficult to read for the patient.
      3. We therefore strongly advise giving out a Summary Note generated on the Practo module only.

9. I don’t have details of the patient to share on the Summary Note. What should I do?
   1. We request you to always start every video consultation by first establishing the patient’s identity and making a note of these details for an update in the Summary Note at the end of the call.
   2. In case the patient is unwilling to share the required details with you, you may choose to not proceed with the consultation and mark the consultation as cancelled explaining your reason as ‘Not being able to establish patient identity’. The guidelines explain that the provider should establish the identity of the patient and document the same on the Summary Note at all times.

10. Whom should I reach out to in case I have confusion regarding issuing the Summary Note?
    1. You can reach out to the Practo support team in case you are facing issues with the prescription module, or feel a certain consultation has been unduly treated as cancelled. Our medical team may reach out to you to understand your concerns and help you further.
    2. If you also need assistance with training requirement on certain aspects of how the module works, our team would be happy to help you out.

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