SCANNING AND ARCHIVING

APPLICATIONS MANUAL

6.0

Table of Contents

General Setup

Background Client Dictionary4

Chart Subcategory Dictionary6

Chart Category Dictionary6

Medical Records Document Dictionary7

Medical Records Chart Order10

Point of Contact

Customer Defined Parameters13

ADM Access Dictionary13

Electronic Chart

Person Profile Access Dictionary26

Person Dictionary 27

HIM access Dictionary32

Archiving

Forms Queue Databases 34

Archiving ADM35

Archiving ITS36

Archiving LAB37

Archiving PHA39

Archiving OR41

Batch Scanning

Scan Desktop Function Set44

Scan Access 45

Scan Station46

Deficiencies

Incomplete Record Reason59

Coding

MRM Parameters67

Profile Dictionary69

Info / System Setup

Make sure the MRM Database is defined on the background client

Info Systems --> MIS -> Background Jobs (NPR) -> Enter/ Edit Client


Confirm the MRM Bk jobs are running on Client

Info Systems -> MIS -> Background Jobs (NPR) --> Process Unique Bkg Jobs

Make sure the following jobs are set up to run:

MRM Chart

MRM Folder Transfer

MRM Forms Queue Job

On the machine that MRM Chart Job will run, install the MeditechPrinter


Medical Record Forms Dictionary

The Medical Record Forms Dictionary is used to define all unique documents used within the hospital, whether generated by MEDITECH or scanned into the system. Any document that is now in your paper chart that you wish to scan or archive must have an entry within this dictionary.

The Electronic Chart’s Categories and Subcategories correspond to the separators currently used to organize the current paper chart.

Info SystemsMISDictionariesAdministrativeMedical Record Subcategory

Define the different Medical Record Subcategories that will be utilized to organize documents in the Electronic Chart.

Info SystemsMISDictionariesAdministrativeMedical Record Category

Define the Medical Record Chart Categories that will be used to organize documents in the Electronic Chart. Subcategories are associated underneath each category.

Info SystemsMISDictionariesAdministrativeMedical Record Documents

Define ALL Documents that will be scanned or archived.

Mnemonic: Enter a unique form mnemonic. An end user should be able to determine the form from the mnemonic entered here.

Name: Full description of the form defined.

Confidential: Y/N – Making this form confidential will only allow HIM users to access this form

Physician Query: Y/N – This will determine whether the form will be used as a physician query form by the coding department

Elec. Chart Document: Y/N – Define if you want the form included in the Electronic Legal Record (ELR)

Document Category: Defines the Chart Category for which the form belongs. This field along with the Document Subcategory will determine where this form is located in the ELR

Document Subcategory: Further defines the Document Category. This is a required field.

Document Source: If this field is defined, this is a MEDITECH generated form that will be ARCHIVED and stored on the patient's ELR. This field is only for archived forms. If the form is not generated from MEDITECH then this field is left blank

Folder Order: This determines what date and time is used to stored scanned Medical Record Forms within the patients ELR

ADM/SVC Date & Time

SCANNED Date & Time

EPISODE Date & Time

Date Review Display Page: This field determines where in EMR the scanned image will be located based on your EMR panels. This allows scanned images to viewed in the EMR. Archived forms are present in the EMR because the data is sent “real time” or automatically once filed.

Signature Required: Y/N - this field is set to “Y” for SCANNED forms that constantly require provider signatures. Example: Physicians Orders

Double Sided: Y/N – define if the form has information on the front and back of the page

Orientation: How information is displayed on the form – Portrait/ Landscape

Roll Up Images: Y/N - Setting this field to “Y” will roll together multiple forms in order for them to be viewed in the ELR as a single, multi-page form.

Point of Contact: Y/N – If “Yes” then the form can be used for Point of Contact Scanning. Only forms set to Yes will appear in the lookup in the POC scanning routine

Context: Insurance/ Other – this field determines what kind of image will be associated with this form. If “Insurance” is selected the user will be required to identify one of the patient's insurance before scanning at POC. “Other” is selected for forms that are not insurance related.

Multiple Images: Y/N – This allows multiple images of one form to be stored on a patients account.

Demo Recall: Y/N – If set to YES, scanned POC images will be pulled forward at the patient's next visit, even if this visit is not flagged for scanning.

Default Image Format: The user will be provided with a lookup to the options for the image format. This is used strictly for POC scanning and will default into the screen. Users are allowed to change this value while using this component. Ex) Black and White, Grayscale, RGB

Default Image Size: The user will be given a lookup to available image sizes. This is used strictly for POC scanning and will default into the screen. Users are allowed to change this value while using this component. Ex) 8 ½ by 11, 8 ½ by 14, 3 by 5.

Database Access: In this field, ADM / BAR databases will have access to scan or view the scanned documents at Point of Contact

Medical Record Chart Order Dictionary

Once you have defined the majority (at least 80%) of your forms, the next dictionary to build will be the Medical Record Chart Order Dictionary. This dictionary determines the organization of the electronic chart. Within this dictionary you will need to put all of the categories in the order you want them to appear in the chart. Under each category, you need to then order your subcategories. Within each subcategory you will enter each form.

Holding the shift key and hitting up or down arrow will allow you to reorder the categories, subcategories or forms easier. The Insert key will allow you to insert a new form, category or subcategory within the order.

AdministrativeHIMDictionariesMedical Record Chart Order dictionary

Define the specific order to which documents are organized in the Electronic Health Record. Documents must be defined here in order to file to the Chart.

Point of Contact Scanning

ADM / BAR

A hospital collects a variety of information at the point of contact (patient’s registration). Forms commonly collected here include: driver’s license, insurance cards, consent forms, living wills, authorizations, photographs and physician orders. There are six different ways to access the point of contact scanning screen in the Admissions module.

The Patient Accounting Department can also scan in documents (EOB, Insurance Correspondence) from the Process Accounts routine in B/AR. The information collected can be sent to Demo Recall, the E-chart and/or EMR.

The POC Scan Screen is a stand alone scanning routine. All parameters need to be activated and setup in their respective applications in order for this routine to be used and viewed.

Each form created in MIS that is to be scanned in either Admissions or BAR must have Point of Contact set to “Yes” in the MIS Forms Dictionary. Otherwise, the form will not appear in the lookups for the scan routine.

Below is the POC scanning screen that is seen at the end of a patient’s registration. The screens and functions shown below are examples from the Admissions module. However, the screens and functions are identical in the Billing module. The only difference is that ADM and B/AR database access must be defined in the MIS Forms Dictionary.

Point of Contact Scanning is based on a patient status. Determine at which patient status you would like to scan in POC forms. Set a “Y” in the Scan field to indicate the user will be scanning POC forms at this patient status.

Administrative -> Admissions -> System Management -> E/E Customer Defined Parameters -> Registration page 3


Define ADM Point of Contact Scanning Desktop for users

Administrative -> Admissions -> Dictionaries -> Access E/E


6 Ways to the ADM “POC Scanning Screen”

There are six ways to reach the Scanning Screen pictured in the ADM module. Five of the following routines listed will allow a user to scan/view all documents with database access set to ADM in the Forms Dictionary. Whereas one routine, the Demo Recall Routine, will only allow forms set to Demo Recall "Y" to be scanned or viewed in addition to having ADM database access.

1. At the end of a Patient's Registration

The majority of POC scanning performed in ADM will take place at the end of a patient registration. The Scanning Screen will appear at the end of both a short-form and long-form registration.

2. Stand alone routine

ADM → Registration Management desktop → Maintenance → Scan documents

This routine gives registration clerks, nurses, and other hospital staff the ability to scan in ADM without registering a patient. All forms given ADM database access in the Forms dictionary for POC will appear in the Form Lookup.

This routine can be used at the end of a busy shift in order to scan consent forms that have accumulated throughout the day. It also can be used for QA analysis as well as a quick and easy way to check routines and find/edit mistakes.


3. Demo Recall Routine

ADM → Registration Management desktop → Demo Recall → Scan

In this routine, a user can view/scan scanned documents that have been set to Demo Recall "Yes" in the Forms Dictionary. A consent of admissions does not appear in the Form lookup because it was set to Demo Recall "No" in the Forms Dictionary. However, Insurance Cards and Photo IDS are two documents that should appear in this Form lookup.

4. Reprint ADM Form

ADM → Registration Management desktop → Account info → Reprint Admission Form

This routine is useful for registration clerks who have lost an admission form that has already been scanned. The registration clerk would use this routine to reprint a new admission form and then scan it into the system. It could also be used if there was any missing information that needed to be reprinted and scanned into the system. All forms given ADM database access in the Forms dictionary will appear in Form lookup in this Scan Screen.

5. Admission Edit

ADM → Registration Management desktop → Registration → Edit

This routine is used to update or modify a patient’s existing demographic information.

6. Mid-Registration Scanning against an Insurance (Admission or Admission Edit)

ADM  Registration Management desktop Registration  Insurance Page

It is possible to flag certain Insurances to pull up the POC scanning screen after filing an insurance to a patient’s admission or registration. This can be set up in the MIS Insurance Dictionary. In order for this function to work, POC scanning must be turned on in the Customer Defined Parameter for the patient status being processed.

For example, a patient with a new secondary insurance payer may bring in a new insurance card to the registration desk to be scanned. The clerk would use this routine to update the patient’s insurance information, as well as scan the new insurance card before filing. All forms given ADM database access in the Forms dictionary and flagged as Insurance documents will appear in this Scan Screen.

The forms to be scanned at the insurance screen in ADM must be entered in the ‘ADM Scanning Form ID’ multiple field. These entries are made per insurance.

POC Functions (Buttons)

Now that the POC screen has been accessed using one of the methods mentioned above. The user will be able to perform certain functions. These functions (or buttons) may be restricted per user from within ADM or BAR via the module’s Access and Option Set Dictionaries.

If the form chosen has a context of insurance in the forms dictionary, then an insurance must be entered in the following field. This will be a lookup in the insurances that have been attached to that patient in the registration process. This field will be left blank if the from has a context of other in the forms dictionary.


This button brings the user into the scanning routine.

The screen below is what will be seen after clicking the Scan button in POC. The user must select which form to scan by doing a lookup into the MIS Forms Dictionary. This lookup will be restricted to forms set to Point of Contact “Yes” and given database access to either ADM or BAR.

This button will scan in a document and make it viewable on the screen. The screen below is the POC image viewer. The functions (buttons) are described below.

Page Up, Down, Go to: These buttons are for multiple page forms.

  • The “Go to Page” allows a user to choose a specific page.

Scan Next: This button allows a user to scan the next page of a document.

Rescan: This button allows a user to replace the document scanned into the system

Options: These are options on how the scanned document can be viewed.

  • The options chosen are the default settings when entering the viewer.
  • There are three choices – 1to1, Fit All, Fit width.
  • 1 to 1 – Shows the actual size of the document scanned.
  • Fit All – Will fit the whole document on the screen.
  • Fit width – Will fit the width of the paper on the screen.
  • The window will automatically maximize – whether Y/N is stated.

Cancel: Rejects the document that has been scanned into the routine.

OK: This approves the scanned document to be stored in permanent storage.

This button allows a user to calibrate the scanner to their specific needs.

In order to view documents with this function, the user must highlight at least one image. Clicking this button will launch the image viewer.

This button deletes any document chosen in the list.

This button will move any documents from one patient account to another.

  • The forms can be moved to a different visit number for the same patient. A form can also be moved to a different patient’s file. This routine will also allow a user to change the name of a document if both accounts and visits are identical. The example below shows that the Consent form for the first patient’s visit becomes the HIPAA form for the second patient. The consent form will no longer exist on the first patient file.

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Example: This button allows users to push images over to a correct visit if images were scanned to the wrong patient. This button can also be used to rename a Form ID, even when the image is in the correct folder.

This button copies any document(s) to another patient folder.

  • Copying a document will result in two patients with the same document on file.
  • This routine allows a user to change the name of a document if both accounts and visits are identical.

Example: When a family, from out of state, comes into the hospital and all family members are on the fathers/mothers insurance. This button will allow the user to copy the insurance card image to all members in the family. The example below shows an insurance card being copied between family members. The insurance card will now exist on both accounts.

This button will allow a user to select certain insurances and other forms.

  • The user is allowed to select only insurances or the insurances attached to the patient’s account.
  • The user can search for forms without any insurance attached to them.
  • The user can perform a search by date.
  • If the user chooses to use the full list, every field should be left blank.

For Example, entering the criteria shown below will search all POC documents for this patient account for an Insurance Card for insurance ABDIBE01 that was scanned (i.e. created) on or after 12/15/05.

This button will allow the user to print the form that is highlighted

BAR Point of Contact Scanning Routines

E/E B/AR Option Sets

Different option sets for POC Scanning can be created within the B/AR Option Set Dictionary for attachment to B/AR Process Screens. Certain functions can be added or restricted from the POC Scanning routine using the “Function” dialog box. The dialog box appears upon hitting <ENTER> in the “Routine” field if ‘Scanning’ is chosen from the F9 lookup. This “Function” box allows certain functions to be added or restricted from the Scanning routine. Once filed, the option set must be attached to access groups in the E/E B/AR Access Dictionary.

BAR MAIN MENU DICTIONARIESDESKTOP ACCESSDESKTOP OPTION SETENTER/EDIT