Scanning and Archiving Module

Training Manual

Electronic ChartAncillary/Clinical Setup

Dictionaries that control Archiving of data to the Electronic Chart

Module: Abstracting

What goes to the Chart Attestation Statement Patient Abstract Utilization Worksheet/Review

Dictionaries/Parameters involvedMIS MRF Form Source Dictionary (Toolbox systems dictionary)There are three form types generated by the Form Initialize routine and available for use in Abstracting. They are:

Form Source Description__________ABS.ATT ABS Attestation ReportABS.REPORT ABS ReportABS.UR.REVIEW ABS UR Review

MIS Medical Records Form DictionaryAt least one form has to be created for each of the three types of Abstracting reports in this dictionary. The “Form Source” will need to be populated with one of the MRF Form Source entries that were created in the toolbox initialize routine.

ABS Form dictionary

Once the MIS Medical Records Forms entries are created, they can be added in the ABS Form dictionary for the 3 type of forms. These are put into the “MIS MR Form” field.

Process that gets the forms to the ChartAs these forms are printed in ABS, they will be put on a queue for the Scanning and Arching module to later pick up. Once the patient has reached the delay days setup in the “Auto Build ____ Days After DIS/SVC” field entered in the Chart Order dictionary in MRI, the MRM Forms Queue Background Job will read the queue entry and create the archive document to be put in the appropriate patient’s Electronic Chart. The form can also be manually queued prior to the delay days by clicking on the compile button in the chart for a patient who has not yet reached the delay days.

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Module: Admissions

What goes to the Chart Admissions Forms

Dictionaries/Parameters involvedMIS MRF Form Source Dictionary (Toolbox systems dictionary)There is one form type generated by the initialize routine and available for use in Admissions. It is:

Form Source Description__ADM.FORM ADM Form

MIS Medical Records Form DictionaryAt least one form has to be created for ADM in this dictionary. The “Form Source” will need to be populated with the “ADM.FORM” MIS MRF Form Source that was created in the toolbox initialize routine.

Customer Defined Parameters

All forms to be included in the electronic chart will need to be defined in the ADM Customer Defined Parameters, Forms and Embossing page, for each patient status. * The forms will need to be associated to a Medical Record Form, from the MIS Medical Records Forms Dictionary.

Process that gets the forms to the ChartWhenever the forms defined in the parameters are printed or reprinted, a program will be called to put an entry on the queue for MRM to read. Once the patient has reached the delay days setup in the “Auto Build ____ Days After DIS/SVC” field entered in the Chart Order dictionary in MRI, the MRM Forms Queue Background Job will read the queued entry and create the archive document to be put in the appropriate patient’s Chart. The form can also be manually queued prior to the delay days by clicking on the compile button in the chart for a patient who has not yet reached the delay days.

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Module: Emergency Department Management

What goes to the Chart Patient Record Patient Audit

Dictionaries/Parameters involved

MIS MRF Form Source Dictionary (Toolbox systems dictionary)

There are two form types generated by the initialize routine and available for use in the Emergency Department Module. They are:

Form Source Description__________EDM.AUDIT Patient Audit ReportEDM.RECORD Patient Detail Record

MIS Medical Records Form Dictionary

At least one form has to be created for each of the two types of EDM reports in this dictionary. The “Form Source” will need to be populated with one of the MRF Form Source entries that were created in the toolbox initialize routine.

Process that gets the forms to the Chart

Any form that is assigned one of the two form sources above will be put on the queue for the Scanning and Archiving module at the time of Registration and then again at the time of Final Status Event (removal from the EDM List). Once the patient has reached the delay days setup in the “Auto Build ____ Days After DIS/SVC” field entered in the Chart Order dictionary in MRI, the MRM Forms Queue Background Job will read the queue entry and create the archive document to be put in the appropriate Patient’s Chart. The form can also be manually queued prior to the delay days by clicking on the compile button in the chart for a patient who has not yet reached the delay days.

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Module: Imaging and Therapeutic Services

What goes to the Chart Reports Orders Questionnaires

Dictionaries/Parameters involved

MIS MRF Form Source Dictionary (Toolbox systems dictionary)

There are two form types generated by the initialize routine and available for use in ITS. They are:

Form Source Description__________RAD.ORDER Radiology OrdersRAD.REPORT Radiology Report

MIS Medical Records Form Dictionary

At least one form has to be created for both of the types of ITS forms in this dictionary for each distinct department who will have their data located in a distinct section of the chart. The “Form Source” will need to be populated with the appropriate MRF Form Source entry that was created in the toolbox initialize routine.

Report Dictionary

Once the MIS Medical Records Forms entries are created, the appropriate entry can be added into this dictionary. These are put into the “Med Rec Form” section. The value of the Med Rec Form in the report dictionary will be saved to a report when one is filed. The Medical Records Form that is attached to the report dictionary will determine where the report will be located in the Electronic Chart. Therefore, separate Medical Records forms with the RAD.REPORT form type will need to be created for the Reports associated with these various departments.

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Category Dictionary

A new Med Rec Form prompt has been added to the Category and Procedure dictionaries. The value of the Med Rec Form in the procedure dictionary will be saved to an order when one is filed. If this value does not exist, the value of the Med Rec Form in the category dictionary will be saved to the order. This will give you the flexibility of being able to have specific Orders from different departments appear in different sections of the Electronic Chart.

Procedure Dictionary

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Process that gets the forms to the ChartAs orders are placed, the appropriate entry for the Medical Record Form in the Category or Procedure that was ordered will be indexed for the Electronic Chart. In addition, as reports are entered for a patient, the Medical Records Form assigned in the Report Dictionary will be indexed for the patient for the Electronic Chart. Once the patient has reached the delay days setup in the “Auto Build ____ Days DIS/SVC” field entered in the Chart Order dictionary in MRI, the MRM Forms Queue Background Job will read the queue entry and create the archive document to be put in the appropriate Patient’s Chart. The form can also be manually queued prior to the delay days by clicking on the compile button in the chart for a patient who has not yet reached the delay days.

The purge routines in ITS were update to prevent orders and reports from purging if their Form has not been created or properly stored by the Electronic Chart.

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Module: Laboratory

What goes to the Chart LIS Patient Summary Pathology Specimen Report (one per specimen) Blood Bank Transfusion Reaction Report

The pathology specimen reports might be MS Word reports or Rich Text reports for CS.

Dictionaries/Parameters involved

MIS MRF Form Source Dictionary (Toolbox systems dictionary)There are three form types generated by the initialize routine and available for use in LAB. They are:

Form Source Description__________LAB.DIS.SUM LAB Discharge SummaryLAB.PATIENT.SUM LAB Patient SummaryLAB.PTH.REPORT LAB Pathology Report

MIS Medical Records Form DictionaryAt least one form has to be created for each of the types of LAB. The “Form Source” will need to be populated with the appropriate MRF Form Source entry that was created in the toolbox initialize routine.Three forms are defined in the Customer-Defined Parameters. For the Summary and Pathology reports, you must also define an LIS Report Format to be used. This gives customers the capability of customizing the output. For the BBK Transfusion Reactions form, a hard-coded report is used.

Process that gets the forms to the ChartWhenever a specimen has activity or a blood bank transfusion reaction occurs, LAB queues entries for the EChart. The EChart software later asks Lab to produce the reports for the queued forms.

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Module: Medical Records

What goes to the Chart Correspondence Letters Accounting of Disclosures report

Dictionaries/Parameters involved

MIS MRF Form Source Dictionary (Systems toolbox dictionary)

There is one Form Type generated by the initialize routine and available for use in Medical Records. It is

Form Source Description____________

MRI.LTR MRI Correspondence Letter

This form type should be used for the Medical Record Forms for Correspondence Letters.

MIS Medical Records Form Dictionary

Letters: At least one form needs to be created for use for Correspondence Letters. The Form Source will need to be populated with MRI.LTR.

AOD Report: At least one form needs to be created for use for the Accounting of Disclosures report. The "Form Source" will need to be blank, as the AOD Report will generate immediately.

MRI Letter dictionary

Within the Medical Records application, each letter with a Type of Correspondence may be defined with a Medical Record Form. The form created for letters should be added into the Med Rec Form prompt. See the example below:

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For the Accounting of Disclosures report, the following new prompt will need the Medical Record Form attached for the AOD report. This is defined in the Enter Edit User Parameters. (30. Additional Patient Routines, 30. Other Routines Menu, 24. User Definable Parameters)

Process that gets the forms to the Chart

Correspondence Letters

When a Correspondence Letter is printed that is attached to a Medical Record Form, it is immediately put on a queue and generates an image for the Chart.

Accounting of Disclosures Report

When an Accounting of Disclosures Report is printed for a patient, and a Med Rec Form has been identified in the User Definable Parameters, an AOD form will be immediately put on a queue and generates an image for the Chart.

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Module: Nursing

What goes to the Chart Profile Discharge Summary Care Plan Spreadsheet MDS Assessments PAI Assessments SB-MDS Assessments

Dictionaries/Parameters involved

MIS MRF Form Source Dictionary (Toolbox systems dictionary)There are seven form types generated by the initialize routine and available for use in NUR. They are:

Form Source Description__________

NUR – CARE PLAN Nursing – Care PlanNUR – DIS SUM Nursing Discharge SummaryNUR – MDS ASMT Nursing – MDS AssessmentNUR – PAI ASMT Nursing – PAI AssessmentNUR – PROFILE Nursing - ProfileNUR – SB MDS Nursing SB MDS AssessmentNUR – SPREADSHT Nursing - Spreadsheet

MIS Medical Records Form DictionaryAt least one form has to be created for each of the reports defined to be archived in the NUR parameters.

Toolbox Parameters (page 7)

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Define report, format and Med Rec form (lookup into the MIS MRF Form dictionary)

Process that gets the forms to the ChartThe Nursing filer programs now set up an entry on the archive queue whenever something new is created, or an edit is made to data that should appear on one of the archive report. For example, a new care plan or path is added to a patient, a note is added to the patient's record, an intervention, goal or diagnosis's status, text or frequency is edited, an MDS Assessment is filed, et cetera. Once the patient has reached the delay days in the Chart Order dictionary, the MRM Background job will process the patient entry from the NUR Archive Queue.

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Module: Order Entry

What goes to the Chart Discharge Summary Administrative Data Departmental Reports

Dictionaries/Parameters involved

MIS MRF Form Source Dictionary (Toolbox systems dictionary)

There is one form type generated by the initialize routine and available for use in ORM:Form Source Description__________OE.ADMIN.DATA OE Administrative DataOE.DISCH.SUM OE Discharge SummaryOE.DPT.REPORT OE DPT Report

MIS Medical Records Form Dictionary

A form for the surgical profile has to be created. The “Form Source” OE.DISCH.SUM, created in the toolbox initialize routine, will need to be added to this form. The 'Electronic Chart Form?' prompt should be set to "Y" to include this form in a patient chart.

OE Parameters

A new parameter has been added to determine what report will be sent to the EChart for the discharge summary and Admin Data Report.

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OE Report Dictionary

A new prompt has been added to define an MIS med rec form for the report to determine where in the chart the report will be locared. At least one form per department will need to be defined, more if you will break out reports into different areas of the chart.

Process that gets the forms to the ChartWhen the first order is placed on a patient, OE filer queues an entry in the archive queue for the Discharge Summary Form. Also when ADM sends patient's admin data to OE or it is updated in OE, an entry is created in in the queue for the Admin Data Form. The MRM Forms Queue bkg job reads the entry and files it in the Chart index, without the image. When a patient is discharged, the MRM bkg job will create entries in the image compile date index for all the forms in the Chart Index at the time. After discharge, if there is any change in the patient's data, OE will requeue the patient.

Once the patient has reached the delay days setup in the “Auto Build ____ Days After DIS/SVC” field entered in the Chart Order dictionary in MRI, the MRM Forms Queue Background Job will read the queue entry and create the archive document to be put in the appropriate Patient’s Chart. The form can also be manually queued prior to the delay days by clicking on the compile button in the chart for a patient who has not yet reached the delay days.

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Module: OR Management

What goes to the Chart Surgical Profile

Dictionaries/Parameters involved

MIS MRF Form Source Dictionary (Toolbox systems dictionary)

There is one form type generated by the initialize routine and available for use in ORM:

Form Source Description__________ORM.PROFILE ORM Surgical Profile

MIS Medical Records Form DictionaryA form for the surgical profile has to be created. The “Form Source” ORM.PROFILE created in the toolbox initialize routine will need to added to this form. The 'Electronic Chart Form?' prompt should be set to "Y" to include this form in a patient chart.

ORM Parameters

The linkage to the Electronic Chart for ORM is defined through the prompt 'EChart Medical Record Form' in the ORM Parameters Surgical Scheduling tab. The EChart Medical Record Form is a lookup into the MIS Medical Records Forms dictionary.

Process that gets the forms to the ChartWhen a surgical profile is verified (or deferred), the Surgical Profile Verify routine queues an entry for the Scanning and Arching module. Once the patient has reached the delay days setup in the “Auto Build ____ Days After DIS/SVC” field entered in the Chart Order dictionary in MRI, the MRM Forms Queue Background Job will read the queue entry and create the archive document to be put in the appropriate patient’s Chart. The form can also be manually queued prior to the delay days by clicking on the compile button in the chart for a patient who has not yet reached the delay daysModule: Pharmacy

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What goes to the Chart Inpatient (print orders, one time orders, & Manually Resolved One Time orders) Discharge (print orders, one time orders, & Manually Resolved One Time orders) Outpatient (print orders, one time orders, & Manually Resolved One Time orders) Intervention MAR Summary ADR

Dictionaries/Parameters involved

MIS MRF Form Source Dictionary (Toolbox systems dictionary)There are four form types generated by the initialize routine and available for use in Pharmacy. They are:

Form Source Description__________PHA.ADR PHA Adverse Reaction ListPHA.CLV PHA Clinical InterventionsPHA.MAR PHA MARPHA.RX PHA RX

MIS Medical Records Form DictionaryAt least one form has to be created for each of the seven types of Pharmacy reports in this dictionary. The “Form Source” will need to be populated with one of the MRF Form Source entries that were created in the toolbox initialize routine.PHA Toolbox Parameters

Once the MIS Medical Records Forms entries are created, they can be added in parameters for the forms. These are put into the “Medical Records Forms” section.

Process that gets the forms to the ChartOnce the patient has reached the delay days setup in the “Auto Build ____ Days After DIS/SVC” field entered in the Chart Order dictionary in MRI, the MRM Forms Queue Background Job will create the archive documents for all of the forms defined in the PHA toolbox parameters. The form can also be manually queued prior to the delay days by clicking on the compile button in the chart for a patient who has not yet reached the delay days. Activity post-discharge on any archived account will cause them to be er-queued and once again processed by the MRM Forms Queue BACKGROUND Job to update the forms in the E-Chart.

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Module: Radiology

What goes to the ChartReports and Addenda in signed status will be queued to go to the chart, and will be sent for each associated exam whose type has a medical record form defined in the Exam Type dictionary.

Dictionaries/Parameters involved

MIS MRF Form Source Dictionary (Toolbox systems dictionary)There are four form types generated by the initialize routine and available for use in Pharmacy. They are:Form Source Description__________RAD.REPORT Radiology Report

MIS Medical Records Form DictionaryAt least one form has to be created for reports in this dictionary. The “Form Source” will need to be populated with the MRF Form Source entry RAD.REPORT.

RAD Exam Type Dicionary

Process that gets the forms to the ChartOnce the patient has reached the delay days setup in the “Auto Build ____ Days After DIS/SVC” field entered in the Chart Order dictionary in MRI, the MRM Forms Queue Background Job will create the archive documents for all of the queued reports/addenda. The form can also be manually queued prior to the delay days by clicking on the compile button in the chart for a patient who has

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not yet reached the delay days. Activity post-discharge on any archived account will cause them to be er-queued and once again processed by the MRM Forms Queue BACKGROUND Job to update the forms in the E-Chart.

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