eHR Content Standards Guidebook - Electronic Health Record Office

eHR Content Standards Guidebook7.4. Referral7.4.1. The referral letter documents the information that is required when a healthcarepractitioner refers all or a portion of a person’s care to another healthcarepractitioner. The referral letter would include the information as discussed inother areas under Section 7.7.5. Episode summary7.5.1. An episode is one or more healthcare services a person received fromhealthcare practitioner for a particular clinical problem or situation during arelatively continuous period. An episode is composed of one or moreencounter(s), see section 7.3.7.5.2. The episode summary contains information that summarize the following :• Reason originates the episode and the person condition during initialencounter• Major diagnostic findings during the course of the episode• Problems identified• Significant procedures performed and other related therapeutic treatment,e.g. medication• The person’s condition, therapeutic orders or treatment plan while preparinga periodic episode summary or upon termination of an episode• Follow-up arrangement• Education to the person / family, if applicable7.6. Adverse reactions / allergies7.6.1. This includes information on the type of biological, physical or chemical agentsthat would result in / is proven to give rise to adverse health effects. Details ofthe adverse reactions, if occurred, should also be included. Absence of theinformation does not imply the absence of the condition.7.7. Problems7.7.1. Problem list contains all active and inactive significant health and social active orinactive problems. Problem can be a diagnosis, pathophysiological state,Version 1.0 Copyright © 2009 – HKSAR Government Page 11 / 18