CERNER SINGLE DOCUMENT CAPTURE

Transcription

1 CERNER SINGLE DOCUMENT CAPTURE Procedure Abstract This procedure covers steps for ambulatory Single Document Capture 2018 V3

2 Ambulatory Document Prep Future State: Document Imaging - Ambulatory Clinical Notes Single Document Capture Eastern Maine Healthcare Systems HIM policy and procedure notes for ambulatory: -Documents received are expected to be culled by providers (the review of medical required to retain outside records that are relevant to the patient s treatment) Providers are expected to perform culling of outside records with the turnaround guidance for scanning below: o Paper results of ordered tests - Within 24 hours of receipt o Records in preparation for a consultation - Culled, reviewed and scanned within 48 hours after visit date

3 o Records as part of a care transfer - Culled, reviewed and scanned within 48 hours after first visit date o Records requested for patient care - Within 48 hours of completion of provider review Practice managers will determine consistent individuals who will be responsible for scanning as to reduce errors The removal of unnecessary portions of a received record should occur under the direction of the provider. Ambulatory Document Prep Start/Stop 1. Receive Documents 1.1. Note: Point of entry may vary. This may be via fax, mail or directly from the patient 2. Verify that the received documents are legible 3. Prep Documents 4. Verifying Patient 4.1. Two identifiers (Name, date of birth, account, gender, address, phone number.hipaa list is not inclusive) 5. Re-ordering Documents as needed grouping documents by type and by order date 6. File documents in ready for scanning area Ambulatory Scanner 7. Remove staples, paperclips or any other physical item holding the documents that may interfere with scanning 8. Power on the scanner 9. Open PowerChart 9.1. Note: opening PowerChart before powering the scanner may result in an error message 10. Navigate to the Patient's chart Locate the patient FIN # - This must be the most recent encounter for your location This can be a visit prior to the date of scanning or a scheduled visit in the future associated with the FIN # For prior encounters that are more than 3 months, an encounter must be created Refer to the Non-Patient Quick Reg process on how to create a FIN # for ambulatory scanning. 11. Open the Clinical Notes tab 12. Select the Scan/Import button 13. Place your documents in the scanner Note: You can scan up to 30 pages at a time Training note: documents can be split after bulk scanning (to be clarified during training- this would be for splitting the indexing) Outside documents should be scanned to the appropriate index

4 14. Select the document type that images should be stored to Change the default date/time to the date of the encounter 15. Click Scan to scan documents Note: If a color scan a window will appear for you to select the appropriate profile 16. Perform a QA check Review the images to ensure the scan quality Is the information legible? Is it in the right patient account? Are all the pages accounted for? Is this indexed to the appropriate grouper? If a quality issue is identified, the scanner should cancel out Below outlines the process for canceling out of the scanning process if you have scanned a document and then realize you are under the incorrect encounter: Select the cancel button A window will appear stating: X page(s) have been saved into the system, any pages not saved will be deleted. Continue? Click Yes to delete all unsaved changes and close the window Click No to return to the document Click Yes The scanning window will close allowing you to search for the correct encounter Re-start the scanning process 17. Select "Sign" once completed 18. Documents are available in the Patient's Chart. 19. A prompt will appear to view notes in chart. 20. Accept the prompt 21. Review the images to ensure the scan quality Is the information legible? Is it in the right patient account? Are all the pages accounted for? Is this indexed to the appropriate grouper? 22. If there is a quality error contact HIM to have the document marked in error 23. This step is for forwarding the scanned document to HIM 24. Select a scanned document from within the Notes tab or Clinical Notes tab of the patient s chart. 25. Click the forward button within the toolbar underneath the banner bar. 26. The Forward Only window will appear. Check off additional forward action (if not checked already) 27. Select Review from the Additional forward action dropdown menu 28. Search/Select the applicable Facility Inbox you wish to forward too. (#Facility, Inbox) is the format to use. 29. Place a comment in the comments field (if applicable). 30. Select Ok. You have now successfully forwarded a scanned document for review.

5 Ambulatory QA Start/Stop 31. Perform Quality Check per Audit Policy 32. Review the images to ensure the scan quality Is the information legible? Is it in the right patient account? Are all the pages accounted for? Is this indexed to the appropriate grouper if no, follow the document correction process