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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.

Process

 

Use the following guidelines when choosing a name, document type, etc.

DocumentDocument typeScan LevelDocument Description
Blue Cross Form (to send)Drug Access/ApprovalPatientBlue Cross Request for Access
Blue Cross Form (reply)Drug Access/ApprovalPatientBlue Cross Access Reply
CBG recordClinical DocumentEncounterCBG record
Consult NoteClinical DocumentEncounter [needs to be created first]Consult <MD name>
Enrollment Form Request (e.g. Evenity)Clinical DocumentEncounter<Drug> Enrollment Request
Enrollment Form Reply (e.g. Evenity)Drug Access/ApprovalPatient<Drug> Enrollment Reply
Enrollment Form Request for More InfoDrug Access/ApprovalPatient<Drug> Enrollment Request for more info
Food recordClinical DocumentEncounterFood Record
Health history FormHistory & PhysicalEncounterOsteoporosis Health History Form
Insulin prescriptionRx PrescriptionEncounterInsulin prescription
Insulin Pump RecordsClinical DocumentEncounter<Brand> Pump Records
Insurance Form, e.g. Sunlife (to send)Insurance/Coverage DocumentEncounterInsurance Form <Company>
isCGM reportClinical DocumentEncounter<Brand> isCGM
rtCGM reportClinical DocumentEncounter<Brand> rtCGM
ZA post infusion report/ Injection NotificationExternal DocumentPatientZA post infusion report/ Injection Notification

Process

  1. 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
  2. Save the document to a secure folder on your computer (Can be an image or a PDF).
  3. If it's a Consult Note you are attaching, create an encounter for the date of the consult. Encounter Type = "Scanned Document" 
  4. Open Media Manager (Press <Ctrl> + <Space> to open Search, then type in 'Media' and <Enter>)
  5. Search for and select the patient.
  6. 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.
  7. Select 'Scan.'
  8. You will get the message "No scan devices found, only import feature will be available." Click OK.
  9. Select the date of the encounter.
  10. Select the Document Type. Incoming Document = 'Clinical Document' 
  11. Enter Document Description, as per table above.
  12. Click 'Import.'
  13. Choose the file from the correct folder on your computer.
  14. Select "Upload the Selected Documents."