Diabetes Educators Calgary Charting Guidelines
Attaching Documents
Attaching Documents in CC (Media Manager)
Connect Care combines health information from many clinics and facilities across Alberta.
- 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.
- Consider summarizing glucose results rather than attaching a glucose record, when appropriate.
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 | Insurance/Coverage Document | 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.'
- You will get the message "No scan devices found, only import feature will be available." Click OK.
- Select the date of the encounter.
- Select the Document Type. For example, Incoming Document = 'Clinical Document'
- Enter Document Description, as per table above.
- Click 'Import.'
- Choose the file from the correct folder on your computer.
- Select "Upload the Selected Documents."