Pre-Implementation Questionnaire Facility Name:

Transcription

1 Welcome to WoundCareMD Pre-Implementation Questionnaire Facility My name is Courtney Reay and I am your implementation specialist for Woundcare MD, the product of choice for your center's electronic health record (EHR). My primary responsibility is to ensure a successful seamless transition from your current documentation process to Woundcare MD. To accomplish this process, the implementation team will need to perform a needs analysis, which involves gathering pertinent information to understand key workflows and organizational priorities. We will also require additional information to establish the database. This exercise will help us make your EHR implementation more efficient. We look forward to optimizing your documentation and outcomes tracking efforts through use of WoundCareMD. An integral part of a successful implementation is a thorough analysis of the end users skill level, readiness and willingness to undertake this change. We recommend beginning the process of identifying and building an engaged team to facilitate this process. We will call to arrange and interactive conference call to review the information submitted. I look forward to meeting you. Thank you for your prompt attention and interest. Courtney Reay WoundcareMD Project Manager EHR Implementation Manager creay@ihsmail.net Phone: Ext.1016 Fax: Emergency Contact: N. Dale Mabry Hwy, Suite 250 Tampa, FL Attestations The information in the fields below, attest that the named individual agrees with the content of this form. Position/Title: Date Completed: / / WOUNDCAREMD Page 1 of 5 QUESTIONNAIRE

2 Please tell us more about your program so that we can determine appropriate WoundCareMD settings and on-site training for your specific users: I.I. Facility Information * Address: * Phone Number(s): Fax Number(s): Company N/A Note:* Filled details will show on all printed documentation in the WoundCareMD system. (i.e. FL.Wound Care & Hyperbaric Center) I.II. Contact Information Facility Contact for Training Program Director Clinical Manager Position/Title: ** Position/Title: ** **List any additional users requiring access to Woundcare MD WOUNDCAREMD Page 2 of 5 QUESTIONNAIRE

3 I.III. Facility Description & Clinical Support 1. What is the current method for patient charting? 2. Is the hospital or department accredited by any agency? Yes No 2a. If Yes, Name of accrediting agency? 3. How long has the program been open? Date: 4. What is your operational program based on? 5. What type of facility is this program in? PT-Based NP Hospital Outpatient LTAC Physician-Based WCON-Based Long Term Care Home Health 6. How many active patients do you currently have? Patients 7. Will you plan to add your active patients in the system prior to going live? Yes No 7a. If No, Will you be providing the details to WoundCareMD to input the information? Yes No 8. How many end users will be using the WoundCareMD system? Receptionist Authorizations Hyperbaric Technicians Nurses Physicians Directors Coders Medical Records I.T Department Monday : Tuesday : 9. Estimate the daily census/patient volume at your location? 10. What are the hours of service for this program? Wednesday : Thursday : Friday : Saturday : Weekdays: Weekends: WOUNDCAREMD Page 3 of 5 QUESTIONNAIRE

4 I.IV. Network & Computing Components 1. Is your plan to have a designated data entry person or point of care? Designated Person Care Provider 2. How many treatment rooms in the program? TX Rooms 3. Do you plan to have a computer/laptop in each room? Yes No If no, where? 4. Describe the current set-up of the equipment? Stationed Mobile Other: 5. What type of hardware will you be using with WoundCareMD? Desktop PC: Tablets : Motion C5 Other: 6. Will you be leasing the equipment from WoundCareMD? Yes No 7. Does the department have wireless internet service? Yes No 8. Do you plan to print hard copies of records or maintain a paperless chart? Yes No 9. What is your time preference to be displayed in WCMD? 12 Hour 24 Hour (Military Time) 10. If you have HBOT, how many chambers do you have? # of Chambers 10a. Is there computer access in this area. N/A Yes No 11. Do you have a relationship with a Management Company in your wound Yes No and/or HBO departments? 11.a If yes, Please provide name and contact details I.T Department Contact Please provide the details below to the best of knowledge about the computing environment: Hardware: Server: Operating System: WOUNDCAREMD Page 4 of 5 QUESTIONNAIRE

5 Section II: On-Site Training Plans II.I. "Go Live" Information 1. What is your anticipated Go-Live date? 2. What are the Conference/Training Room Amenities? 2a. Are there enough computers for each user. 3. How many end users will need WCMD on-site training? *** ** Note: Read Only users and physicians will be trained via web-based education. Internet Access Telephone Yes Computer Projector No Receptionist Authorizations Hyperbaric Technicians Nurses Physicians Directors Other: II.II. Comments Please make additional comments regarding your facility, your staff, and your plans for implementation of the EHR. This will help WoundCareMD Program staff understand your unique circumstances so that we may provide better support to you in this effort. Feel free to include any specific questions or concerns you may have. Submit the information electronically via to or fax to WOUNDCAREMD Page 5 of 5 QUESTIONNAIRE