After Visit Summaries for Everything, including Surgery

There’s more than a few blog posts here about after visit summaries. I received this additional support for After Visit Summaries from my former colleague and quality improvement expert extraordinaire Martin Stabler (who is also an exceptional photographer – during our improvement work together, his beautiful photographs captured the passion of people dedicated to improving patients’ experiences, and through them we could see that this is just about every person in health care).

We have After Visit Summaries, why not a Post Surgery Summary?

I recently had occasion to wait anxiously in a waiting room for a surgeon’s summary of a family member’s operation.

The familiar process: surgeon comes out to waiting room, family gathers around, noisy backgrd, stress high, family listens intently but stress reduces ability to process and retain the info.

Surgeon leaves, family processes the info, then calls and emails others. As the “information” ripples out from person to person, more mis-information accrues just like in the game of “telephone.”

With a written summary in hand the doc could go over it with the family, post surgery. Families would be incredibly grateful, and could refer back to it and use it to pass on a more accurate report, instead of having to make it up from memory. Car repair shops give written summaries, we give summaries for simple office visits, but not for visits that involve complex, potentially life-changing situations.

Anyway, a thought… –Martin Stabler in Portland

To our surgical colleagues – are any of you innovating in this area? To fellow patients. does this situation sound similar to yours?


Can you please explain physicians' inability to connect the dots on record access, clear communication, patient education, physician transparency, better health, fewer errors — FEEDBACK – fewer lawsuits?

Just review The Great Kibbe Debate "Confessions . . . " on thcb Either total DEAFNESS to patient record access or total hostility (You pay! We don't profit directly from communication!)

Existing protocol for surgeons is totally manipulative, in my view. They stun the patient into compliance with Worst Case Scenario First — and in my daughter's case, this was a KID! who got stunned with the scenario of losing use of her hand — bring in best or most reasonable case scenario. They come out of surgery with the "good news", the patient falls at their feet in worship.

I fell for most of this, until I got records. After literally prying the records out of the hospital, I discovered:

1 the year of discovery of the tumor was off by one — think about that! This was my error, speaking from memory.

2 The surgeon knew going in he wouldn't be getting a margin, but didn't tell us. The trade-off was "marginal margin" for quality of life in the short run but higher recurrence danger…. There was no discussion of radiation therapy until the window had closed. They had simply preempted this discussion by omitting key surgical information.

In my experience, doctors don't want patients to access records because they are opposed to transparency, which is the only ethical way to proceed.

Please, as physicians, can you come up with some other explanation than doctors resist someone "checking their work"? A feedback loop may reduce physician prestige, but it also decreases error long before the situation achieves lawsuit status.

No one can process auditory information accurately under the situation described. This is simple logic, but why does the medical community remain wedded to this idea?

Hi Chris,

I love the question, and the way you ask it, as a "why?" When I read it, I thought of lots of reasons why doctors are raised this way and was prepared to type them here.

Then I realized, I don't know why for sure. Is professional prestige or autonomy more important than someone's health in the mind of a physician? I don't think so.

Maybe some physicians health care providers could share stories about when/how they learned not to share records with patients (if that's how they practice),and if they still don't share, why?

I'll tweet your comment and see if we get some interesting responses,


Post op Instructions:

We have been working on these as AVS for about a year, and have several. The challenge: post op instructions are delivered at the hospital. And, as far as templating them, the inter surgeon variations make standardization challenging.

We do have several example of procedure prep instructions, that we have on our EMR system, and would be happy to share screenshots.

The After Visit Summary provides great information patients can refer to later. My question is; does having a printer in the exam room increases the use of AVS by providers?. Any studies on this subject?

Angeles Juarez

At Colorado Kaiser Permanente, we have had an EMR since 1997. We upgraded to a windows based EPIC version in 2004, which included a Visit Summary report. to explore barriers to use of visit summaries, we actually did a study of printer availability, proximity to exam room, and number providers using the printer at a time, and found NO correlation between printer availability and use of visit summaries. Several clinics with the highest visit summary percentage had the fewest printers. Most important factor: Intent to communicate, leadership support and provider feedback. The effort requires 3 new physician behaviors: putting instructions in writing, reviewing written instructions with the patient, and handing out a copy of the instructions before the patient leaves. Many clinics have different people doing these three parts, ie personel closest to the printer hands the copy to the patient, after the physician reviews instructions on screen in the exam room. but it starts with physician instructions that are specific to the patient. We also did market research which indicated that people are more satisfied with the visit experience overall, and with provider, when they receive written instructions at the visit.

Greetings M., and thanks for your question!

I knew that Paulanne would have good data for you as an expert in this area, and I can also tell you from many observations that I have seen terrific AVS behavior (collaborative creation of the AVS) with printers and without printers, and poor AVS behavior with and without printers – poor behavior being defined as not creating the AVS collaboratively and printing an almost blank sheet of paper from the exam room.

One interesting finding that I have seen and learned about is that the After Visit Summary provides great information to support staff, too, so printing out where they are allows them to participate in the care and add another check to the plan via their knowledge of the patient's situation.

Feel free to expand more on what you're seeing/experiencing in Minnesota and Paulanne and others can chime in with any information that will help you. Agreed that it's a great tool,


Ted Eytan, MD