Patient Chart: Documents

The following topics are discussed on this page. Use the links to jump to the desired subject:

Working with Documents

The Documents page displays existing patient documents in sections, when available:

Authorization	This section displays authorization documents.
Chart Notes	This section contains chart notes.
Digital Signature	This section displays the digital signature document/scanned document(s).
Insurance Card	This section displays the scanned insurance card document(s).
Medical Summary	This section displays medical summary documents, e.g. CCDAs.
Patient Education	This section contains informational documents that have been printed and given to the patient. This may include disease education and treatment instructions.
Patient Education (Facility-based)	This section contains information regarding facility-based educational documents given to the patient, i.e. smoking cessation, discharge instructions, etc.
Transcription	This section contains transcribed documents and displays the document type, date/time, and dictating practitioner.
Radiology Results	This section contains result reports from Radiology tests and displays the test name, date/time, and result status.
Scanned Documents	This section contains documents that have been scanned and attached to the patient chart. This section displays the document type, document name, description, and date/time. You can filter this list by using the Filter and Dividers field. The Filter field provides options to display by Visit, MPI, or both. The Dividers field provides options based on document type. Note: To ensure quick loading of the page, 4 documents at a time are displayed with a page count control to page through additional documents.
Clinic Visit Summary	This section displays Clinic Notes and summaries of the patient visits to the clinic.
Referral	This section displays referral documents and images.
Transcription	This section contains transcribed documents and displays the document type, date/time, and dictating practitioner.

Documents that are PDF, JPEG, BMP, PNG, and TXT file types are viewed by clicking the file icon located to the right of the document name.[+]

Documents that are created/generated in the Centriq applications are listed in the appropriate section and may have some of the following function buttons to the right of the document:

	This PACS Image Viewer button indicates that an image from a 3rd party PACS viewer can be viewed for this order (In the Radiology Results section only). Click this button to launch a new window and view the image. (Note: Setup Required for PACS integration. Contact your Healthland Account Representative to set up this feature.)
	Show Details: Click this button to display additional details regarding the document, such as Visit Number and Patient Class Type.
	Problem: Click this button to display the Problem List. You can select or add a problem. (See Problem List for details on using this list.)
	Edit: Click this button to display the details of the document to view and/or modify the document.
	Print: Click this button to print the report in that row.
	View Document: Click this button to view the document. From this view of the document, you can print the document by clicking the Print button. For some documents, there will be no View icon. To view documents, click the Print button. This will display the document in a viewer that can also be used to print the document.

When the Clinic Note is generated it is listed in the Clinic Visit Summary sections. The following options are available for Clinic Notes:

	View Clinic Visit Summary: Click this button to display the Clinic Visit Summary document. You can print a hard copy from this view.
	Download: Click this button to download an electronic copy of the record, i.e. to email the document to the patient and/or provider.
	Add Addendum: Click this button to add additional information to the Clinic Note.

To search the documents list

The Documents tab contains multiple search options to locate and view the specific document(s) you are looking for.

Using a keyword search

You can do a text search by typing a keyword in the Search by field. Then, click Search.

Using the Narrow Your Search options

The left side of the screen provides options to narrow your search. You can narrow your search by Visits, Date, Source, Document Type, Creator, Chart Note Type, and/or Available Visits. Select the options in any and/or all of these sections to define your search criteria. As you select the criteria, the page is refreshed displaying documents that meet the selected criteria.

NOTE: If you have not enabled the document search feature, you can do so by going to Maintenance > Document Search and check the Enable Document Search option. Appropriate user security is required to access this setting.

By Date: Select an option in this category to limit the results by the date the document was created.
By Source: Select an option in this category to limit the results by the source or how the document was created, e.g. transcription, etc.
By Document Type: Select an option in this category to limit the results by the document type, e.g. chart note, etc.
By Creator: Select the creator's username(s) to display documents created by those users.
Be Chart Note Type: Select an option in this category to limit the results by chart note type.
Available Visits: Select the visit(s) that you would like to display documents from. Select All to view all documents for the patient's MPI.

To view Patient Education

To view Patient Education documents, click Patient Education. The Patient Education window is displayed. Documents are displayed in two sections: Patient Education and Patient Education (Facility-Based).

To add a facility-based education document

From the Documents page, click Add Facility-Based Education. The Add Patient Education page is displayed.
In the Select Education field, begin typing the topic of the document. Matches to the typed text are displayed. Select the appropriate topic. The topic text is displayed in the Instruction field.
The Charted Date / Time default to the current date and time. Modify, if necessary, using the calendar and clock icons.
In the Instruction Given To field, select the person(s) that the education document is being given to. Check or uncheck the desired option(s).
In the Level of Understanding field, select the appropriate level of understanding for the person(s) receiving the education.
In the Education Completed By field, add the user(s) who completed the education for the patient and/or family. To add a user, type the first few letters of the user name to display a list of options. Select the desired user from the list and click the + button. The selected user is added to the list. To add another user, repeat this step. (To remove a user, click the - button next to the user you wish to remove. )
If desired, click the Diagnosis button to display the Problem List. You can associate a problem from the list or add a new one. (See Problem List for details on using this list.)
The Instruction field displays the content of the education document. If desired, make edits using the following methods:
- Click in the document and type additions or remove unwanted text.
- Change formatting using the font, size, and text and paragraph formatting tools.
- Print document using the Print button.
- Toggle the document to Full Screen Mode using the computer button.
Click Save. (To start over, click Clear. The document and related selections are cleared from the screen. Or, click Cancel to return to the Documents page.)

To launch Patient Care Instructions

To launch the third-party database (ExitCare) of patient care instructions to create an instructional handout, click Launch Patient Care Instructions. Documents created in ExitCare are displayed in the Patient Education section. For additional instructions, see the application help available from the ExitCare application.

To mark a document as erroneous

Marking a document as erroneous removes it from the document list.

Click the Edit button,, located to the right of the desired document. The Edit Patient Education page is displayed.
In the Reason field, use the drop-down list to select a reason to mark the document as erroneous.
Click Mark Erroneous. You are returned to the Documents page and the document is removed.

To edit a document

Click the Edit button, , located to the right of the desired document. The Edit Patient Education page is displayed.
The selected document is displayed in the Select Education field.
In the Reason field, select the appropriate reason from the drop-down list for editing the document.
If desired, modify the following fields:
- Charted Date/Time - Displays the date and time that the document was created. Modify, if necessary, using the clock and calendar icons.
- Instruction Given To - Displays the person(s) that the education document was given to. Check or uncheck the desired options to display the correct information.
- Level of Understanding - Displays how the person(s) that the education was given to understood the content. Change as desired by checking the appropriate level of understanding.
- Education Completed By - Displays the user(s) who completed the education for the patient and/or family. To add a user, type the first few letters of the user name to display a list of options. Select the desired user from the list and click the + button. The selected user is added to the list. To remove a user, click the - button next to the user you wish to remove.
The Instruction field displays the content of the education document. Make edits as appropriate using the following methods:
- Click in the document and type additions or remove unwanted text.
- Change formatting using the font, size, and text and paragraph formatting tools.
- Print document using the Print button.
- Toggle the document to Full Screen Mode using the computer button.
Click Update.

To print the document list

The document list can be printed by clicking the printer button, . From the Print dialog window, select the appropriate printer and click Print.

To print an individual document, click the View Document button located to the right of the desired document, then click the printer button.

Or, to print or save multiple documents, click the check box located next to the documents you wish to save and/or print. Then, click Export. The PDF documents are displayed. Use the File >Print or File > Save functions to print or save the documents.