Electronic Medical Record Scanning Procedures

Files available for scanning in records:

  • OP Reports and Pictures: All DISD physician Op Reports and pictures from surgery are scanned in this file. It appears in the chart in BLACK print and does not need to go to the Physician/Assistant work list.
  • PA Dictation: Transcription files the Physician Assistants dictation into this file. It appears in BLACK print and requires the supervising physician to sign off, so it does need to go the Physician/Assistant work list.
  • IME from non-DISD provider: All outside IME’s are to be scanned in this file. It appears in BLACK print and needs to go to thePhysician/Assistantwork list.
  • Transcription: Transcription electronically saves the dictation into this file. These appear in BLACK ink and needs to be signed off by the dictating physician. NP packets are to be scanned under this file.
  • Diagnostic Reports: ALL Diagnostic reports i.e. MRI, outside x-ray, CT Scans, Bone Scans, Labs, Pre-op Clearances, are to be scanned in this file. These reports appear in BLACK print and need to go to the Physician/Assistant work list to be signed off by the ordering physician.
  • SX Scheduling Forms: SX forms requesting authorization. These appear in HOT PINK print and do not need to go to thePhysician/Assistant work list.
  • Insurance/Registration Forms: Copy of insurance card and registration forms go in this file. It appears in RED print and does not need to go to thePhysician/Assistant work list.
  • Authorizations/Referrals/Eligibility: This file needs to include authorizations for diagnostic tests, PCP referrals, and Eligibility reports. They appear in HOT PINK print and do not need to go to thePhysician/Assistant work list.
  • Billing Letters/Financial Agreements: This file is for the billing department. Anything scanned in this file will appear in GREEN print and do not need to go to thePhysician/Assistant work list.
  • Case Manager/Adjuster Requests: Anything from a nurse case manager or adjuster that requires the response of either the physician or the assistant. This will appear in MAROON print and needs to go to thePhysician/Assistant work list.
  • Consultations: All hospital consultations done by a DISD physician need to be scanned in this file. The document will appear in BLACK print and does not need to go to thePhysician/Assistant work list.
  • Correspondence: All written documents from the patient to DISD, including email traffic between DISD staff and the patient. These will appear in GREY print and need to go to the Physician/Assistant work list.
  • Disability Forms: All Disability forms, handicap placards, FMLA forms for the spouse or the family member of the patient. These will appear in BLUE print and do not need to go the Physician/Assistant work list.
  • Legal: This file is for the Medical Legal Coordinator. These documents will appear in PURPLE print and do not need to go to the Physician/Assistant work list.
  • Medical Records Release Forms: All Medical Records Release forms, whether a DISD form or an outside form. They will appear inPURPLE print and do not need to go to the work list.
  • Outside Records: All records from a non DISD physician. This includes records collected for NP’s. These records will appear in BLACK print and do not need to go to the Physician/Assistant work list.
  • Physical Therapy Notes: Outside P.T. notes. They will appear in OLIVEprint and do not need to go to the Physician/Assistant work list.
  • DISD P.T. Plan of Care: DISD P.T. notes. They will appear in OLIVEprint and do not need to go to the Physician/Assistant work list.

Please Note: Use only the folders listed above, we are in the process of eliminating folders that are not needed in this practice.

Whatdo thecolors represent?

The documents that are printed in black let the physician know that those documents are directly related to patient care such as DISD physician notes, non DISD physician notes, diagnostic reports, lab results, etc. This helps save time during clinic by not having the physician going through everything in the chart when all he/she needs is a report.

Most of our patients develop large charts over time and color coding the various documents that are required by law to be kept in patient charts helps everyone with visual cues to locate items needed.

How to “Name” the documents that we scan?

Each document scanned into MDPlus must have the following information included when filling in the description;

  1. The date of service on the document, or the date of the document if not a medical document.
  2. The FULL name of the document, for example MRI LSpine, CT Scan CSpine, EMG LUE (left upper extremity) NOT MRI, CT, EMG, etc. It is important that the physician know what the document is BEFORE he opens it. Not to mention most patients end up having more than 1 MRI during treatment, so it is important to have the date of service visible in the chart. There are only 2 exceptions to this rule, one is NP outside records, and they can be scanned in together. Although we need to label these records as “NP outside records” not APPT request. The second exception is “Pre-op Clearances”, these can also be scanned in as 1 document as long as they are received together. Sometimes patients require additional clearances by other specialists, so those would be scanned in as separate documents as “081606 Surgical Clearance Dr.So-and-soPit/LDS”.
  3. The treating DISD Physician’s last 3 digits of their name must appear after the description. For example, PIT, HES, or SON. As we continue to expand we need to begin labeling the provider since our patients will be seeing more than one DISD physician.
  4. Lastly, you must put your initials after the physician initials so that there is accountability with everyone scanning.

Some Examples: 20070816 MRI LSpine Pit/LDS

20070822 EMG LUE Pit/LDS

20070812 Pre op Tests Pit/LDS

20070815Cardiology Surgical Clearance Dr. Smith Pit/LDS

20060816 OS (outside) P.T. Progress Note Pit/LDS

*** OS indicates that the service is not from DISD

20060816 P.T. POC (plan of care) HES/LDS

Important Reminders

Before shredding your document, make sure that the copy you scanned is legible in the electronic chart. This includes insurance cards!! If you receive a poor quality fax that needs to be scanned, call the facility and ask them to re-fax the document and if it continues to be a problem, tell the sender to mail us a clear copy. Anything and everything we put into a patient’s EMR becomes a legal document that can be ordered by a subpoena and there are legal liabilities if we present records that are poor quality and not legible.

Abbreviations: These are standardized in medicine and we can not use our own made up abbreviations. If you do not know what is accepted by the AMA (American Medical Association), write things out. If you are interested in the most updated approved abbreviation list, let me know and I would be more than happy to provide you with one. Again, this is a legal issue and we must abide by the regulations set for us at all times.

All Diagnostic Reports that arrive either via fax or mail can go directly to the scan box. These items go to the work list and it is not necessary that they get viewed twice. The one thing to keep in mind is if we get behind in scanning, we need to prioritize our scanning and all reports, test results and outside consults need to be scanned within 24-48 hours from the time of arrival.

When scanning records that were reviewed put them under “outside records” and label them NP outside recordsand put the Appt Request as the last page. This will help the doctor during clinic.

CONSISTANCY and PRIDE IN ONE’S WORK!!! (Speaks for itself)

ALWAYS look and make sure that you are not rescanning a document that is already in the EMR. We often get the same document several times, it is really frustrating for the physician to see the same document more than once when it appears on the work list, plus it is extra work for staff. Please, Please, Please be aware of what you are scanning.

It is the responsibility of the entire staff to take responsibility in ensuring that all of our charts are maintained not only with integrity but that we follow all guidelines that are established by DISD and outside entities, i.e. HIPPA, State and Federal Laws.

Since there are several different items that can go under the same “folder” please label documents what they are. For example, in the past I have seen thingsunder Insurance / Registrationthat were generically labeled, example Aetna or HIPPA. Be more specific, Aetna Ins. Card or Eligibility Report depending on what it is. Instead of HIPPA, say “Notice of Privacy Practices”, or even “signed HIPPA form”. Bottom line…it should be clear as to what the document is before it is opened.

MAKE SURE YOU ARE SCANNING DOCUMENTS IN THE RIGHT CHART!!! I received a subpoena on a chart and while preparing the documents that needed to be sent to the judge, I noticed 2 reports that did not belong to that particular patient.

If documents that are scanned in by you are found to be poor quality, unreadable, labeled incorrectly, in the chart multiple times, etc., be prepared to be given the task of making the necessary corrections.

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