Soarian Enterprise Document Management (EDM) Physician Training Document for Scanned Documents and Dictated Deficiencies

Transcription

1 Soarian Enterprise Document Management (EDM) Physician Training Document for Scanned Documents and Dictated Deficiencies January/2014

2 Completing Physician Deficiencies Sign on to Soarian Clinicals and choose the Links option in the upper right corner Select the Soarian EDM option On the Home page you will see lists the number of records/deficiencies assigned to you. Choose the deficiencies to be completed by clicking on the word of the deficiency. To choose ALL deficiencies choose Complete All Dictate Documents that need to be dictated by you. Missing Info - Documents with incomplete information Verbal Orders VORB or TORB requiring Signature Signature Documents that need to be signed by you Coding Query Questions sent to you from the Coding Staff Complete All All encounters and documents with deficiencies that are assigned to you 2

3 The Split Folder/Document Display window will open once you select an option. The Filter: field will dynamically change based on the type of deficiencies selected on the Completion Status window. In the example below, the Priority was selected on the Main Menu. All deficiency types will be included in this option. Complete the Deficiencies The process used to complete deficiencies will vary slightly depending on the deficiency type. The samples below show the steps for the three basic types of processes Encounter Level Deficiencies (e.g. Dictate and Waiting) The deficiencies at the top of the worklist are for documents that are missing in the encounter folder. These deficiencies have a deficiency icon ( ) in the document tree instead of a document icon ( ). Typically this would be applied to the patient encounter if a document was missing and needed to be dictated. An example would be a discharge summary. The icon looks like this.( ) 3

4 The deficiency icon in the example above ( ) is for Dictate of a Discharge Summary. Double click on the deficiency top display the navigation tools. Follow the directions in the Deficiency. Here are the functions to navigate the deficiency.: to skip back to the previous deficiency. The deficiency is not completed. to skip to the next deficiency. The deficiency is not completed. to show/hide notes related to the deficiency. to send the deficiency back to the analyst. to complete the deficiency. If the deficiency/document has been completed, you must enter the Dictaphone Job ID to ensure the deficiency processes properly. The deficiency box will turn green and the deficiency will be removed from the work list. Enter the Dictaphone Job ID number and press Done. 4

5 Signatures 1. Signature ( ) deficiencies are placed on documents ( ) within the encounter folder. The deficiency box will be placed by the analyst at the location where the signature is required. If multiple signatures are needed, multiple deficiencies will be placed on the document. 2. Review the deficiency and then choose one of the following options from the deficiency box: to skip back to the previous deficiency. The deficiency is not completed. to skip to the next deficiency. The deficiency is not completed. to show/hide notes related to the deficiency. to send the deficiency back to the analyst. to sign the document. 3. When the document is signed, the deficiency box will turn green and the deficiency will be removed from the worklist. The signature line is added to the actual document at the location of the deficiency box. NOTE: The signature line includes the user's name and date/time of the signature. The time is displayed in local time with an offset from GMT time (e.g is -4 hours from GMT time. 5

6 To see information behind the deficiency, click on the to redisplay the deficiency or click on the to hide the box. Re-click button at the top of the screen When a document has been annotated and you cannot view the information behind it click on the button to hide the annotation. Re-click to redisplay Coding Query 1. Coding Query deficiencies can be placed on documents ( ) or at the encounter level ( ). The location will depend on whether the question is related to a specific document or the entire encounter. 6

7 The physician will receive a deficiency in their worklist to complete a Coding Query. The physician actually completes the deficiency by clicking the Edit button on the deficiency, which displays an electronic form (PN0012 eprogress Note) and he/she will fill out the progress note or answer the Coding Query question within the eprogress. The physician will then sign and click done on the eprogress Note. Once the physician completes the Coding Query it will be routed back as a PN0012 eprogress Note to the Coder that assigned the Coding Query to the physician with a Misc Analysis Deficiency assigned to the Coder. 2. Clicking on the EDIT button will display the following form. The Physician can type the response, click on sign and then click done to complete. Failure to click Sign will result in a Signature deficiency at a later date. The entered information will not process if you do not click Done. 7

8 Test, Ptest1 2. To view additional patient encounter information in a folders format Exit out of the Display tab by clicking on the x (this was previously the trash can icon) From the Home page choose the Split Folder/Document display Enter the Encounter no in the Quick find below 8

9 To search for additional patients by either Medical Record Number or Encounter Number, use the Quick Find option at the bottom of the page 4. If you are already in the EDM Application and need to broaden your search, or if you have limited information, you can search by choosing the Retrieve Folders function on the sign on screen 9

10 This will allow you to specify by facility And include the Enrollee (patient name) and Admit /Discharge dates. 10