Physician Chart Completion Via SCM ScanDocs Tab

Transcription

1 Physician Chart Completion Via SCM ScanDocs Tab Physician Completion 1

2 Table of Contents Revision History... 2 Chart Completion Workflow Overview... 3 Changes from Current Practice... 3 Benefits of Chart Completion Workflow... 3 Physician Completion Steps... 4 Log On... 4 ScanDocs Tab... 5 Dashboard...5 Inbox... 6 Document Viewer... 8 Completion Password... 9 Changing your completion password... 9 Completing a Signature Deficiency Completing an Annotation Deficiency Adding an Addendum to an Existing Document Returning a Deficiency to the Analyst Deficiencies Filter Missing Item (Dictate) Deficiencies Revision History Revision # Date Description Author/Contributors Created 6/5/2008 Created Physician Completion Teresa Michael Document Revised 6/30/2008 Added physician information Teresa Michael/Dr. Silverstein Physician Completion 2

3 Chart Completion Workflow Overview Chart Completion Workflow, an accessanyware (AA) module, is a Chart Deficiency Management system for the Health Information Management Services (HIMS) Department. It provides the ability for HIM Completion Analysts to electronically analyze records for completeness of the medical record and subsequently allows physicians to electronically sign the analyzed scanned documents. Utilizing the integration between Sunrise Clinical Manager (SCM) and accessanyware via the ScanDocs tab, physicians can electronically complete all deficiencies to include transcribed documents currently residing in SCM and scanned documents currently residing in AA. Changes from Current Practice In addition to the implementation of a new module, some changes to our current practice will be evident: 1. Transcribed reports from Dictaphone will be available both in accessanyware and in SCM 2. Free text notes will be viewable in accessanyware Although these documents are now available in accessanyware, these documents, in addition to SCM orders, will continue to be signed via SCM Signature Manager. Benefits of Chart Completion Workflow Provides the ability for physicians to complete ALL scanned and electronic deficiencies from SCM Provides the ability for HIM Completion Analysts to electronically analyze scanned records for completion Eliminates paper record processing in HIM Electronic chart deficiency management reports Provides online physician reminder and suspension letters Provides online analyst productivity reports Provides online JCAHO reporting statistics Physician Completion 3

4 Physician Completion Steps Log On After logging on to SCM, select a patient from the patient list A patient name and visit must be displayed in the Banner Bar in Order to activate the ScanDocs Tab. If STRM-IT is not already running on your workstation, you will receive this message to indicate the STRM-IT Client has started. If the STRM-IT client is running, the STRM-IT Smiley face icon will display in the tool tray. Physician Completion 4

5 ScanDocs Tab Click on ScanDocs tab Two new tabs are available under the ScanDocs Tab Dashboard Inbox Dashboard 1. Identifies the number and type of outstanding deficiencies 2. The deficiencies Include the following: a. Scanned Document deficiencies b. Transcribed Document deficiencies that need to be signed in Signature Manager c. Imported free text documents generated from SCM 3. Does not include: a. SCM orders signed in Signature Manager Physician Completion 5

6 The button will take the clinician directly to their Completion Inbox. The button will refresh the Dashboard information with any new deficiency information Inbox The Inbox is the user interface for the physicians to complete their deficiencies on scanned documents only. NOTE: When you first access the Inbox, the scroll bar goes to the very end of your list so in order to see your deficiencies, you will need to scroll back to the top. Scanned Document Deficiencies Scanned document displays in Viewer Comments display in the Clinician work area Action Buttons Deficiencies in Red are the oldest deficiencies that are nearing the delinquent level and should be given priority in the completion Process Physician Completion 6

7 The Inbox also includes a listing of SCM deficiencies imported into accessanyware. These deficiencies are listed under External Deficiencies For ease of use, you might want to collapse the External Deficiencies by clicking on the minus (-) sign in front of the folder The Dictaphone transcribed document displays in text format The Comment reminds the physician to complete this signature in SCM The Action Buttons are deactivated for External Deficiencies. Physician Completion 7

8 Document Viewer Completion Inbox uses the same Document Viewer used to view documents via the ScanDocs Tab. Using the DOCUMENT VIEWER TOOLBAR, you can perform several actions to manipulate the view of the displayed document. The actions you can perform from the DOCUMENT VIEWER TOOLBAR are the following: Page forward and Page back Number of pages in Document Fit to Width Fit to Height Fit to Page Rotate Clockwise Rotate 180 degrees Rotate Counter-Clockwise Mirror flip about Vertical Axis Mirror flip about Horizontal Axis Zoom In Zoom Out Print (If you have print security) Magnify (See Below) Zoom based on percentage When selecting the Magnify icon, hold down the left mouse and move the cursor over the area of the document you wish to magnify. When finished, deselect the magnify icon. Physician Completion 8

9 Completion Password Completion Workflow requires a completion password for the first signature only. This password is session-based so if the physician logs out of SCM, the physician will be prompted for the completion password a second time. The physician is not prompted for the password until the Complete Deficiency button is clicked the first time. The completion password is defaulted to the physician s user name. It does not expire but can be changed at any time by the user. Changing your completion password The completion password can be changed by the physician: 1. Highlight any deficiency 2. Right click 3. Select change password Physician Completion 9

10 4. Type in your new password 5. The next time you log in, your new password will be effective. Physician Completion 10

11 Completing a Signature Deficiency 1. Click on the first deficiency 2. Click the Complete Deficiency button in the Clinician Work Area if this is the first deficiency of this session, you will be prompted to enter a Completion Password Enter your password and click OK Your Completion password is defaulted to your User Name 3. The deficiency is completed and the workflow automatically rolls to the next deficiency. The completed deficiency is now preceded by a green check mark. Physician Completion 11

12 The green check mark indicates this deficiency is now signed. The red box indicates the location of the physician s electronic signature. The HIM Analyst places this box on the document NOTE: The Signature Server runs every minute to burn completed signatures and annotations onto to the documents. Completing an Annotation Deficiency An Annotation deficiency is a type of deficiency where the physician needs to complete or edit a scanned document. This deficiency does not add a new page but allows the physician to fill in a blank or add a note to an existing page. The HIM Analyst assigns the annotation deficiency and places the box in the appropriate spot on the document 1. When the physician clicks the Complete Deficiency button, the annotation text box displays. 2. The physician can, then, type the requested annotation 3. When finished, click Complete Physician Completion 12

13 4. If you click Save, the document will remain on the physician s work list and the physician will be prompted to sign this document the next time he/she logs into the system. Text Box The analyst can add a comment or instructions for the physician NOTE: If the physician has an annotation deficiency and a signature deficiency on the same document, the system will not allow the physician to complete the signature deficiency prior to the annotation deficiency. A message box displays instructing the physician to complete the annotation deficiency first. Adding an Addendum to an Existing Document The physician has the ability to add an addendum to an existing document even if there is no assigned deficiency to do so. 1. Highlight the document to which you want to add an addendum 2. Click the Add Addendum button in the work area 3. The text box displays 4. When finished click Save and Sign Physician Completion 13

14 5. If you click Save, the document will remain on the physician s work list and the physician will be prompted to sign this document the next time he/she logs into the system. Returning a Deficiency to the Analyst In case of a misassigned deficiency, the physician can route the deficiency back to the analyst with comments by clicking the Return Deficiency button, inserting a comment, and clicking return. Physician Completion 14

15 Comments are predefined or free form Deficiencies Filter The physician can filter all deficiencies by clicking filter in the lower right corner of the work area. Click on the deficiency type you want to complete Missing Item (Dictate) Deficiencies A Missing Item deficiency usually requires the physician to dictate a particular type of document such as a Discharge Summary. This will appear on the work list as a Missing Item Deficiency. Physician Completion 15

16 Identifies type of report missing in this case, an Operative Report. The Comment box identifies any special instructions dictate report In order to dictate a Discharge Summary, the clinician may want to review the remainder of the record. Clicking the Go to Chart button will send the clinician to the complete document stored in accessanyware. The accessanyware record will include all items that have been scanned and all transcribed Dictaphone documents. Physician Completion 16

17 To view results in SCM or other SCM information, the clinician will need to click on the Patient List tab and search for the visit. Once the dictation is complete, the clinician will need to return to the ScanDocs tab to complete the deficiency. Physician Completion 17