Diabetes Educators Calgary Charting Guidelines

Attaching Documents

Attaching Documents in CC

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 DescriptionExample
CBG recordClinical DocumentEncounterCBG recordCBG record
Consult NoteClinical DocumentEncounter [needs to be created first]Consult <MD name>Consult - Dr J Smith
Food recordClinical DocumentEncounterFood RecordFood Record
Insulin prescriptionRx PrescriptionEncounterInsulin prescriptionNotes indicate faxed to __ pharmacy
Insulin Pump RecordsClinical DocumentEncounter<Brand> Pump RecordsOmnipod Pump Records
isCGM reportClinical DocumentEncounter<Brand> isCGMLibre isCGM
rtCGM reportClinical DocumentEncounter<Brand> rtCGMDexcom rtCGM

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."