OneContent: Managing Deficiency Assignments

Transcription

1 OneContent: Managing Deficiency Assignments ONECONTENT 01/25/2018 Overview OneContent contains specific assignments that can be created for identifying and assigning physician deficiencies. Create Missing Signature Deficiency Signature deficiencies are assigned to a document if the physician, resident, or mid-level practitioner has not signed. 1. Click to select the document page that requires a signature. 2. Open the Deficiencies menu. 3. Click the pencil icon. A purple signature box will display on the page. 4. Click + Drag the purple box to the location where the signature should reside. 5. Select a provider. Note: The Select Physician dropdown is pre-populated with providers who are associated to the patient's account. Providers become associated to the patient when at least one of the provider s document has flowed into OneContent. 6. Type a reason in the Enter Reason text box. IM LE ARNING & DEVELOPMENT 1

2 7. Check Priority, if applicable. Note: Priority designation is governed by HIM policy. You should only check the priority box if the account and/or document meets policy guidelines for prioritization. 8. Click the ASSGN checkbox. Leave the default date and time unchanged. 9. Click Save. Add Second Signature OneContent will auto-generate physician and second signature deficiencies for transcribed documents. For all others you will need to create a second signature deficiency. 1. Follow the steps outlined to add a signature deficiency. 2. Click the Require Second Signature checkbox. 3. Select an associated physician from the Select Physician dropdown or check All to search for a different physician. 4. Click Save. Note: The supervising physician can see the deficiency on their worklist but is unable to complete it until the resident or mid-level has signed first. Missing Text Deficiency Missing Text deficiencies are assigned when key information is missing from documentation. For example, a physician may not have included a clinical impression or an admit diagnosis. 1. Click to select the document page that is missing information. 2. Open the Deficiencies menu. 3. Click the text icon. A yellow box will display on the page. 4. Click + Drag the yellow box to the location where the text should reside. 5. Click + Drag edges to expand the box. LEARNING & DEVELOPMENT 2

3 6. Select a provider. 6. Type a reason in the Enter Reason text box. 7. Check Priority, if applicable. 8. Click the ASSGN checkbox. Leave the default date and time unchanged. 9. Click Save. Missing Document A missing document deficiency is assigned if an identified documentation is not present in the chart or the document that you have reviewed is missing a significant amount of information. This deficiency is also referred to as a dictation deficiency. 1. Click the microphone icon. 2. Select the Missing Document type from the Doc Type dropdown. LEARNING & DEVELOPMENT 3

4 3. Select a provider. 4. In the Enter Reason text box, type the name of the missing document. 5. Click the ASSGN checkbox. Leave the default date and time unchanged. 6. Click Save. MEDITECH Deficiency Guidelines In this section, we will review some special considerations regarding assigning and managing deficiencies for MEDITECH patient document. Signature Deficiencies on MEDITECH Orders the physician has not signed the electronic order in MEDITECH before the patient is discharged, he should sign the order in Meditech first. After the physician has signed the order in MEDITECH, he will return to OneContent to complete the deficiency. Physicians can decline a signature deficiency for an order in OneContent for several reasons such as wrong patient or not the supervising physician. Declined deficiencies are routed to a declined queue. Declining the order deficiency in OneContent will not clear the MEDITECH order from MEDITECH s sign queue. The physician can reject the order in MEDITECH to remove it from their signing queue. LEARNING & DEVELOPMENT 4

5 PDOC Documents Due to how PDOC documents are delivered to OneContent, you should use the missing document button for all deficiencies. PDOC documents are identified with a P at the end of the document type. You may see two document versions listed one is a plain text document and the other is a pdf. ALWAYS add the deficiency to the PDF version. Indicate in the reason field whether the deficiency is missing text, missing signature, or missing document type deficiency., add a note for the physician to sign the document in MEDITECH. PDOC Status Types you are reviewing a PDOC document, verify the signing status in MEDITECH. PDOC documents can be one of three statuses. 1. Documents in a signed status have been signed in MEDITECH by all associated physicians. the PDOC document status is signed and the document is in OneContent, no signature deficiency needs to be assigned. 2. Documents in an Isigned status have been signed by at least one physician, but there are other associated physicians who have not signed yet. the PDOC document is in an Isigned status, it typically will not transmit to OneContent until ALL associated physicians have signed. 3. Documents in a Draft status have not been signed by any physicians. PDOC documents in a Draft status will not transmit to OneContent. Is document in MEDITECH? Is document in OneContent? Meditech Signing Status then Yes Yes Signed Do not assign deficiency. Yes No Signed Research and check Forward Advantage. This can occur if the interface between MEDITECH and Forward Advantage is down or there was an error. Yes Yes Isigned There is at least one outstanding signature; verify signing status in MEDITECH and assign deficiency for the outstanding signatures. This could occur because the physician may have added an addendum after the document was signed. Yes No Isigned There is at least one outstanding signature; verify signing status in MEDITECH and assign deficiency for the outstanding signatures. Yes Yes Draft This can occur if the physician added an addendum after the document was signed. The physicians saved the amended document as DRAFT and did not re-sign. Yes No Draft Assign Deficiency. No No Assign Deficiency. LEARNING & DEVELOPMENT 5