Diabetes Educators Calgary Charting Guidelines
Attaching Documents
Attaching Documents in CC (Media Manager)
Source documents that we scan and upload to Connect Care must be saved for 45 days, then discarded. For digital copies, once they are uploaded to CC, they can be deleted.
For paper records:
- FMC - Educators scan paper documents. Provide paper to Admin Support who will stamp "Scanned" and send to Health Records.
- RGH - Provide documents requiring scanning to clerical. Clerical scan and send paper copy to Health Records
- RRDTC - Educators scan the documents. Place paper copies in the Desk 1 chart room in the ‘Scanned Documents’ basket in Desk 1 chart room. Desk 1 Admin Support will stamp and send to Health Records.
- SCHC - Educators scan the documents. Keep paper in locked filing cabinet for at least 45 days. Talk to your team about whether you will keep a shared file (like you used to do for SHC DIP Rx) or if you will keep your own documents in your office. After 45 days (or 2 months if easier to keep track) you can shred all kept documents.
- SHC - Educators scan the documents. Keep paper in locked filing cabinet for at least 45 days. Talk to your team about whether you will keep a shared file (like you used to do for SHC DIP Rx) or if you will keep your own documents in your office. After 45 days (or 2 months if easier to keep track) you can shred all kept documents.
- SMG - Educators scan paper documents. Provide paper to Admin Support. They will keep in locked filing cabinet for at least 45 days and then shred.
Additional Notes:
- Use the correct Document Type, Document Name, etc, so that you and others are able to find the document you're looking for. Detailed information can be found here.
- To correct (change) a document type (e.g. from clinical to insurance for IPTP eligbility) go to the big red EPIC on top left inside CC. Choose Media Manager. Search your patient. Highlight the correct document. Click "Edit" on the Media Manager top toolbar.
- Consider summarizing glucose results rather than attaching a glucose record, when appropriate.
- Application forms should be filled out by the patient (or family member/friend) rather than being filled out by the provider. In those situations, the document does not need to be attached to the chart.
- In the rare case where the provider fills in any part of an application form, it should be attached to the CC chart. If any part of the application form includes financial information, "Quanum ECS" should be used. Social Workers have access to Quanum, but others would need to arrange access if required.
For direct Quanum ECS scanning (e.g. Non-AHS Application Forms) see page 19 & 20
Use the following guidelines when choosing a name, document type, etc.
| Document | Scan Level | Document type | Document Description |
|---|---|---|---|
| 24 h ABPM loan agreement | Encounter | Financial Agreement | Loan agreement - 24 h ABPM device |
| Blue Cross Form (to send) | Patient | Drug Access/Approval | Blue Cross Request for Access |
| Blue Cross Form (reply) | Patient | Drug Access/Approval | Blue Cross Access Reply |
| Blue Cross Pump Eligibility | Encounter | Insurance/Coverage Document | IPTP Eligibility Form |
| CBG record | Encounter | Clinical Document | CBG record |
| Consult Note | Encounter [needs to be created first] | Clinical Document | Consult <MD name> |
| Enrollment Form Request (e.g. Evenity) | Encounter | Clinical Document | <Drug> Enrollment Request |
| Enrollment Form Reply (e.g. Evenity) | Patient | Drug Access/Approval | <Drug> Enrollment Reply |
| Enrollment Form Request for More Info | Patient | Drug Access/Approval | <Drug> Enrollment Request for more info |
| Food record | Encounter | Clinical Document | Food Record |
| Health history Form | Encounter | History & Physical | Osteoporosis Health History Form |
| Insulin prescription | Encounter | Rx Prescription | Insulin prescription |
| Insulin Pump Records | Encounter | Clinical Document | <Brand> Pump Records |
| Insurance Form, e.g. Sunlife (to send) | Encounter | Insurance/Coverage Document | Insurance Form <Company> |
| IPTP Participant Responsibility | Encounter | Consent Agreement Waiver | IPTP Responsibility Agreement |
| isCGM report | Encounter | Clinical Document | <Brand> isCGM |
| rtCGM report | Encounter | Clinical Document | <Brand> rtCGM |
| Therapy Start Form EMAIL to Data Analyst | Encounter | Clinical Document | IPTP Therapy Start Form |
| ZA post infusion report/ Injection Notification | Patient | External Document | ZA post infusion report/ Injection Notification |
Process
- Ensure that the desired document identifies the patient.
- Have the patient include their name at the top. Ideally, there should also be a date of birth and PHN.
- At the very least, enter the patient name in the "Document Description" when uploading the document
- Save the document to a secure folder on your computer (Can be an image or a PDF).
- If it's a Consult Note you are attaching, create an encounter for the date of the consult. Encounter Type = "Scanned Document"
- Open Media Manager (Press <Ctrl> + <Space> to open Search, then type in 'Media' and <Enter>)
- Search for and select the patient.
- Directly under the MRN, you will see "<down arrow> Patient:" If the scan level of the document should be "Encounter", click the down arrow and select "Choose an encounter". Select the encounter that the document should be attached to.
- Select 'Scan.'
- If you have a scanner attached to your printer, load the document in the scanner, and it will be attached to the information you entered.
- If you do not have a scanner attached, you will get the message "No scan devices found, only import feature will be available." Click OK. You will use the "Import" button in the next step.
- Select the date of the encounter.
- Select the Document Type. For example, Incoming Document = 'Clinical Document'
- Enter Document Description, as per table above.
- If you do not have a scanner attached:
- Click 'Import.'
- Choose the file from the correct folder on your computer.
- If saved to your personal drive (\\calfs:), go directly to the document.
- If saved to your One Drive, go to PC > C: Drive > Users > your username
- Select "Upload the Selected Documents."
- Original documents are retained for 45 days (details to come).