After-visit summary checklist

The document has a federal definition. CMS defines the clinical summary as an after-visit summary that gives a patient relevant and actionable information and instructions, and lists what it holds:

• your name, and the provider's name and office contact information;
• the date and location of the visit, and the reason for it;
• the current problem list;
• the current medication list and medication allergy list;
• procedures performed during the visit;
• immunizations or medications given during the visit;
• vital signs taken during the visit, or other recent vital signs;
• laboratory test results, and a list of diagnostic tests still pending;
• clinical instructions;
• future appointments, referrals to other providers, and future scheduled tests;
• demographic information held in the record;
• smoking status;
• care plan fields, including goals and instructions; and
• recommended patient decision aids, where they apply to the visit.

Your copy may use different labels or leave out sections that don't apply. Nothing in that definition is a transcript of the conversation, so treat the summary as one source and call the clinic when an instruction is missing or unclear.

You may get the summary as a printout at checkout, as a page or PDF in the patient portal, as an attachment or link the clinic sends, or as a document shared with an authorized caregiver.

MedlinePlus says patient portals commonly let you view visit summaries, test results, and your medical history including medicines, and let you make non-urgent appointments and ask questions through secure messaging. The menu name depends on the organization, so if you can't find it, message or call the clinic and ask where post-visit instructions are posted. A test results screen or a billing summary is a different document and won't hold the same information.

Several documents describe the same visit and they aren't interchangeable. The after-visit summary is written for you and covers the visit and what comes next. The clinician's visit note is written for the medical record and documents the encounter in clinical detail, so it may use terminology that was never meant as patient instructions. Your portal may offer both under different labels.

Discharge instructions are a third thing. If you're leaving a hospital rather than an office, follow the patient-facing discharge instructions the hospital gave you. MedlinePlus keeps a separate discharge planning page, and that handoff can involve equipment such as a hospital bed, a walker, a shower chair, or oxygen, along with help at home for bathing, dressing, cooking, managing medicines, and getting to appointments.

Read the summary once and mark each relevant line as one of four things, because turning every line into a checkbox is the mistake that makes the list useless.

• Action. Something the summary explicitly asks you to do, such as scheduling a follow-up or completing a named task.
• Reference. A result, a diagnosis, a medication list, an education section, a restriction, or a precaution that should stay available without becoming a daily task.
• Question. Wording you don't understand, an apparent conflict, or a missing detail the clinic needs to fill in.
• Administrative. Phone numbers, portal instructions, billing, and other logistics.

A result is not automatically an action. A restriction loses its meaning when it gets shortened. Medication wording should never be paraphrased into a new instruction.

Fill this in only from the original summary, and copy the wording rather than tidying it up.

• The visit. Date, clinician or clinic, and where the original summary is saved.
• Confirmed actions. What the summary explicitly asks you to do, who is responsible, and the exact timing, frequency, or deadline.
• Appointments, tests, and referrals. What needs booking, who to contact, when results are expected, and how they'll reach you.
• Medication information to verify. What the summary shows as new, changed, continued, or stopped, and the questions for the clinician or pharmacist.
• Restrictions, precautions, and contact instructions. Copied word for word.
• Questions and conflicts. What's unclear or differs from what you remember, and who you'll contact about it.
• The next step. The next action you'll take, and when you'll read the list again.

Don't use the worksheet to invent a dose, shorten a restriction, interpret a result, or decide whether a symptom is urgent. AHRQ says to ask for written instructions and to call the doctor when you don't understand them once you get home. MedlinePlus says to write down any new questions about your health, medicines, or treatment, and to keep a record of your symptoms and all of your medicines.

Four lines from an invented summary, sorted, show how differently they behave:

• Schedule a follow-up within two weeks. An action. Call the clinic and hold the two-week timing.
• Review and follow the activity restrictions in the attached handout. An action that points at reference material. Read the handout and keep the restrictions in their original wording.
• Imaging report is available in the portal. Reference. Keep it with the source and leave it as information until the care team assigns something.
• Call the clinic if the written instructions differ from what you remember. A conditional action. Keep the condition attached to it, and keep the clinic as the contact.

One line schedules care, one points at instructions to read and follow, one applies only if its condition happens, and one is a result. Three of the four create follow-through, and they don't create the same kind.

Some questions have one correct place to go, and a checklist is not it. Call the clinic or the pharmacist for any of these:

• what a result means for your care;
• which instruction applies when two of them conflict;
• whether a symptom is urgent;
• starting, stopping, or changing a medication; and
• changing a restriction, a dose, a frequency, or a follow-up date.

AHRQ says to talk with your doctor or pharmacist before stopping any prescribed medicine, and to call the office when your symptoms get worse or when you're having trouble following the instructions. If the original instruction is unclear, ask the clinic instead of writing yourself a cleaner version.

A summary can carry your name, date of birth, diagnoses, medication details, account numbers, and contact information, and sometimes details about someone else. Keep it where you keep sensitive things, share only what a person needs, and strip anything unrelated before you send it on.

A caregiver can work from the same list when the patient has authorized access. Keep the source, the questions, and the follow-through list together, so both people are reading the same instructions.

I never interpret a result, resolve a conflict between two instructions, or decide that something is urgent. What I do is keep the summary you photograph, read it back to you in plain words, hold only the lines that explicitly ask something of you, and text you about those until each one is done or handed back to the clinic. Booked, called and left a message, still waiting on the referral: all of those are real answers, and I keep track of which is which.

No clinician reviewed this page. It restates the CMS, MedlinePlus, and AHRQ pages linked below, and those, and the original wording of your own summary, are the documents to trust over anything here.