Diabetes Educators Calgary Charting Guidelines

Attaching Documents

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.

Document	Document type	Scan Level	Document Description	Example
CBG record	Clinical Document	Encounter	CBG record	CBG record
Consult Note	Clinical Document	Encounter [needs to be created first]	Consult <MD name>	Consult - Dr J Smith
Food record	Clinical Document	Encounter	Food Record	Food Record
Insulin prescription	Rx Prescription	Encounter	Insulin prescription	Notes indicate faxed to __ pharmacy
Insulin Pump Records	Clinical Document	Encounter	<Brand> Pump Records	Omnipod Pump Records
isCGM report	Clinical Document	Encounter	<Brand> isCGM	Libre isCGM
rtCGM report	Clinical Document	Encounter	<Brand> rtCGM	Dexcom rtCGM

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:" 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. 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."

Attaching Documents in CC