Home Forums Discussions Problems Reviewing and signing off multiple labs

My wife and I are relatively new A/C users, about 4 months now. Patty has a mature IM practice which we are converting from paper into A/C and has a lot more "incoming" labs, old records, test results, etc than I do. Our staff scans, names and drops items into appropriate folders in A/C's imported items area, which of course each show up as a message in the inbox for us to sign.

Any tips from you long-time users on reviewing and signing off on stuff? We're finding it very cumbersome to:
1. Click on message in inbox
2. Bring up long list of things to sign
3. Click on desired lab or whatever
4. Review it and sign off, which closes the list, returning one back to the Inbox
5. Click on next message in Inbox, bringing up the same long list, minus the one you just signed, and repeat.

Adding to this is the fact that when something is imported into the "no sign off needed" folder, it still shows up in the inbox as if it's something that needs sign-off. That's frustrating, too.

It really takes a long time to sign off on 8 or 10 things, seems to us, especially Patty, who is really getting steamed. Can anyone make any suggestions, describing the process you use to review and sign things? I could drink the FAP cool aid, I guess? Any other thoughts?

Many thanks - Jim

So far I haven't jumped into having stuff go right into the messaging system. My incoming faxes stay paper until we're done with our response and then it gets scanned with handwritten annotations. The only exception is the Labcorp interface which is awesome and comes directly into the patients chart and the mailbox.

Version 4 is probably going to change my work flow. It is much better arranged for handling the incoming stuff and I'll probably start having everything get scanned first. Which means I might just have the faxes come into an e-mail system or updox.

Jim,

The FAP Koolaid is pretty good. I don't use the import section much, but what do you mean by "no sign off needed" folder?

Kevin is right that V4 may solve a lot of your problems.

How important is it to you to actually "sign off" these documents. In other words, with a different setup, would simply grabbing the stamped signature from Adobe or using one of the many already made stamps such as Reviewed (which gives the date and time) work? I would think it would.

Jim,
I'm wondering how you are importing the items, especially the old records. If you are scanning and saving the item, then importing into AC though the "import new" button in the imported items tab of the patient's chart... the message in your inbox should be "Signoff: CHART ITEM for JOHN DOE". If you double click this message, the "Sign-off Multiple Imported Items" window should pop up, where you can fill the check boxes for all the ones that just need to be signed but not addressed (old records)... and they will rapidly disappear from your inbox. This may be the list you are referring to when you note "1. Click on message in inbox
2. Bring up long list of things to sign"

If you don't like going to the Multiple Sign-off list for the ones that need individual attention, you can pull up the imported item from your inbox message list by right clicking on that message. This brings up a menu that includes "Pull imported items"... which does just that, and the items that have yet to be signed off should be appearing in red. After addressing it, you can sign-off on this by right clicking on the red item and choosing "sign-off item".

I use UpDox to import new faxes that come in (faxes come into my network as a PDF). When using this to import, the message in my inbox says "IMPORTED: yada yada yada", the yadas of course being whatever my staff enters in as the subject as they are importing in UpDox. Unfortunately I haven't found a way to have these items (with the "IMPORTED" message) show up on the "Sign-Off Mutiple Imported Items" list, but it doesn't bother me too much since these faxes usually need to be addressed individually anyway. If using UpDox, you can have the system send or not send a message with each import...that's the only way I can get the "No Sign-off Needed" items to come in needing sign-off (which I do only by accident).

Our labs are coming in via PAML. The problem is, all the test are reported separate. So when I may have ordered a CMP, lipid profile and TSH, I have to sign off 3 separate labs! Imagine how many labs are in there when you have just a few (or many) people who get them done...

It can be overwhelming to face an inbox full of items that I don't need to see that have to be signed off as well as labs and messages - not to mention any charts I've not completed.

I've not been keeping up with what to expect with V4, but it sounds like I'll soon have reason to celebrate a bit.

Barbara

The LabCorp interface lumps the labs together and I can sign them off together! So CMP, lipids, TSH display altogether (or they can be displayed individually if your are interested in just one value), but the sign off applies to all of them. Not only that, but it seems to lump them by requisition - if a patient has an order for CMP, lipids, and TSH, and a separate order for a HgbA1C, they come in as 2 labs.

Thanks for the replies, folks.

Yes, the lab interface (we have one with Quest, which is probably 70% of our labs) helps. I find it slower to open, though, than just a scanned PDF.

And yes, the "sign off multiple items" window is the frustrating one to which I was referring. It really would be nicer if, after opening an item and signing it, I would be returned to this list, not to my inbox. Thanks for the right-click idea - I hadn't noticed that. I think that will help.

The "no sign off needed" folder is in there, prenamed in the list of potential folder names in the imported items section. Any item that is dropped into that folder does not need to be signed off by anyone; it doesn't "turn red" when my nurse drops it in. That would be great, except it DOES still show up in my message box as an "imported item requiring" something. If I double-click on it, I get a message that I have nothing to sign off (which is true). If I right click and then open the imported items folder, I see nothing that needs any sign-offs. I like this folder for things such as old records I have already seen, registration forms, and legal stuff such as HIPPA and other consent forms, records release forms, etc. I just wish that they could just be put into the chart silently, without a message popping up into the message list.

Bert, what improvements there there likely will be in Version 4 with regards to imported items? Can I reassure Patty that things will get better? She's getting close to switching back to paper charts, truth be told.

Thanks!

Jim

Jim,

Check with support. It sounds like you may have a glitch in your sign-off. When my nurse scans something that doesn't require sign-off it doesn't show up in my in-box.

Bruce.

Hi Bruce,

As I was telling Jim, I don't use that feature much, so I am unaware of the ins and outs.

For my benefit, how would your nurse scan something that doesn't require your signature, i.e. how do you not get it in your inbox.

Thanks in advance.

For example, an insurance card, or signed release of information form, or any other ppiece of non-clinical information, etc.
I don't know. It just doesn't show up to my in-box.

G'Morning All,

I would love for the insurance card and other info not to show up in my box to sign off. PLEASE share how this is done!


Barbara

Just a thought again. Not sure how it would work for others or if it is even viable.

But, I see no reason why you can't make another doctor or elevate someone's prileges so you can send certain things to that inbox. They could then be signed off in batches.

As far as licensing, I think it is all about intend. Two "real" users sharing one license would be wrong. Having a workaround to increase efficiency is a totally different thing.

Of course, be careful of the out of sight, out of mind phenomenon.

Bert, I don't so far know of any way something can be imported into a patient's chart such that I don't get a message about it.

When a new patient comes in, we have a small packet of registration forms they fill out - demographics, insurance info, a copy of the insurance card and driver's lic., consent for old records and a privacy practice statement. These 5 or 6 pages are scanned in a single PDF file and then drag-dropped into the "no sign off required" folder, and named "reg".

Similar items, like an updated insurance card copy, and any subsequent non-clinical BS, are also put into the "Non-Medical Info" folder in the imported items area. It does not require sign-off, but I do get a prompt in my message box that there is an imported item for that patient that needs my attention. When it really dcoesn't. Maybe I will talk with support about it - perhaps I'm doing soemthing wrong. The only way we ever get stuff into the chart - other than our Quest lab and Midmark ECG interfaces - is by drag-and-drop of PDF files into the importned items window. Maybe using another method will not generate this useless prompt? Dunno.

Anyhow, Happy Thanksgiving everybody.

Jim

If you drag an item into imported items you will recieve a message requesting sign-off. If that item is subsequently moved to the non-medical folder, it will not be there to sign-off and it will be an empty message. Scanning directly (and I assume choosing file import) to non-medical doesn't bring up the window asking staff to choose which provider to send the item to.
Or, at least that is my experience.

Hmm, that was originally after rainy, but I missed the chance.

Can you name a new "doctor" called Demographics or No Inbox or something and have the staff import to that "person?" Then that same person could go in and import it. It would then be in the patient's chart, but you wouldn't have to see it.

I suppose I am at a disadvantage (and I apologize) since I do not know much about this non-medical folder. How about just dragging and dropping into the Imported Items window which should give you that prompt?

Bert's solution would probably work. We did that for order forms for the radiologist we use.

Jim,
I hadn't realized you can just "drag and drop", and tried testing it in my office to see if I could reproduce your issue...

When I would drag a file into the "other" or "radiology" folder, it would ask my receptionist who the provider is that should sign off on it (even tho I'm the only provider)...and the message would show up in my inbox as it should.
When I would drag a file into the "non-medical" folder, it would not prompt to name a provider to sign off on it... and I would get no message.

So, unfortunately I couldn't reproduce the problem. However, you might try importing by clicking the "Import New" button located above the imported items list. It will ask you to locate the file, but as long as all the scanned items are saved into the same folder every time, it shouldn't take long (it defaults to the last used folder imported from). If you choose the folder to be "non-medical" it shouldn't prompt for a provider signoff, but any other folder should, though I suspect a bug in your program and the problem likely persists.

One benefit of using the Import Item button over drag and drop is that you can name/describe the imported item rather than using the number assigned by AC. Also, if you check the box "delete original after importing" it will rid the file from the folder to which it was originally scanned.

Interestingly, with the testing of the system above, I've come across a solution to a problem I asked about last week regarding deleting imported items (trying to link to it unsuccessfully)... anyway, the answer to that problem was that it doesn't delete the actual file from the folder if the file is being "previewed" in the imported items page.... thanks

These are all great ideas. Given the variety of questions and answers and the lack of being able to reproduce everyone's bugs, it may be a good idea to get some insight from the man who actually invented the Imported Items.

I sent an email to Jon to see if he would add a post or two here and maybe clear up some things for all of us.

Does that sound like a decent idea?

Jim, long time no see buddy. How's it going down in the land of the world's greatest gumbo?

I agree w/ you, the stuff that doesn't need to be viewed by you would be nice to have it turned off. Here's a couple tips:

1) my faxes come in as PDF's rather than paper. I review the faxes, take appropriate action, then place them in a shared network folder called "OK TO FILE." My staff looks at this continuously through the day and files when they have time between calls. When my inbox clutters up, I double click one of the items to be signed, click "Check all" at the bottom of the multiple sign-off window, the click "sign."

this totally avoids having to go into individual charts, which is VERY slow. I've already reviewed these PDF's when they originally came in. So consider reviewing them before they are imported into AC

2) once you do the above step, anything that shows up but does not require you to sign, you can simply delete those notifications.

See ya my friend,
Adam

Leslie does something very similar. Adam has simply come up with a slight variation. Reviewing the files BEFORE they are imported seems like a good alternative to try. If I didn't use FAP, I think I would use that method as well.

Adobe, and other 3rd party versions of Acrobat, allow many ways to document on the files. If one uses the doctrine that staff who make less money than the provider should do the things they can, then it makes sense for your staff to do the busy work, i.e. importing and other things, while we are in the rooms making money.

I know that Leslie uses Paperport, and I just helped a colleague of Adam's and mine set up a Brother MFP. Most of the more expensive Brother MFP's come with Paperport, which allows you to mark up files and work with them easily.

Bert is correct. I use Paperport (which came with my Brother MFC). Everything now comes in via fax and what comes in the mail is scanned into this. From here I review, mark-up, return refills or move documents into one of several different Paperport folders... "Ready to Import", "Physician to Sign Off", or the folders of each of the employees. For instance, requests for release of medical records go to the billing person, things that need to be scheduled or acted upon go to the front or back office persons. My staff then looks at their folders throughout the day, act upon documents there and then either import them or send them back to the "Physician to Sign Off" folder for my final review. Throughout the day when they get a few minutes, they import documents from the "Ready to Import" folder into charts ( just as they would have filed them into paper charts). This system pretty well mimics how my office ran when it was papered. By the way, all staff can see what is in each others' folders, should a patient call in about a test result that may be waiting for action in someone else's folder. Unlike the email function of AC, this allows easy access for everyone to most everything.
Another great thing about this system is that I can access everything from home. I can do a lot of work therefore in the comfort of my jammies.
But one word of advice. Make sure you back-up your Paperport often. For some reason I have had entire folders simply disappear. It is definitely subject to unintended deletions by anyone using it and I have had to restore the folders more than once. This is my biggest complaint with this system.

Leslie

PS
Adam!!! Glad to see you back!

Leslie,

Are you using a regular server setup? Do the Paperport folders reside on one computer? It seems like it would be important to have every bit of data (AC, billing, Paperport folders with files) all residing on one drive which would be backed up nightly.

Leslie,
I'm glad you are happy to see me back.
It's been a tough year.
After my wife's passing, I moved my office, then a month later sold my home and moved a few streets over. During the fall and early winter I've been remodeling extensively all by myself.

I would agree w/ Bert, if you aren't doing so keep all these network folders on one computer, either your server or main computer. Back them up nightly. You could set sharing properties so that no one can delete them, which might protect against accidental deletion.

Yours Truly,

Fellows,

Yes I have a real server (two actually, an older one which I now use as an external hard drive for extra back up) and the received fax folder resides on the main server. However, it is only backed up nightly. There is a whole lot of work that goes on during the day, faxes coming and documents being moved from folder to folder. I do not know how I would be able to do a continuously running back up to protect against boo-boos that happen during the course of the day. Sometimes at lunch, if I think about it, I will back up the folder to an external hard drive but I forget more than I remember (I am old, you know). The one saving grace, I presume, is that what came in one time can conceivably (if called for and requested again) could come in again. But, many times we do not always know what has come in if it has not yet been "processed". Don't get me wrong, this does not happen daily but I have had to restore Paperport at least 3 times (twice it was I who apparently made the boo-boo while working from home. Well, once I was down at my campsite by the river and Corona may have been involved).
At one point we were scanning old charts into Paperport and keeping them there until they were imported into the charts. Sometimes though, when we got behind on our "filing" the scanned records may have stayed there for several days. In the interim, those old paper charts were sent to "paper heaven". I am embarrassed to say that we totally lost 2 charts this way when Paperport simply somehow deleted the folder they were in . So now, we instead immediately batch import into AC from the Scansnap Scanner and keep a running list of whose imported items still need to be renamed and put in the appropriate "file" which we all do in our free time. And, we have boxes and boxes of scanned papers sitting around waiting longer to go to the shredder.

Leslie
P.S. Hope you are getting things squared away, Adam

Oh, and one other thing I forgot to mention is that I do not think there is anyway to prevent accidental deletion while using Paperport. And, regretfully, these deleted itmes do not go into the recycle bin.

Leslie

Not sure exactly how your network is set up. One thing, though, if you are using the server directly, actually sitting at the server console, then any file or folder you delete will go to the recycle bin. For some reason, which only Microsoft can explain, if you delete the file across the network, then it will not go to the recycle bin. I NEVER delete a file from the server from a client computer unless I ABSOLUTELY know I don't need it.

If you are using Windows 2003 Server or SBS 2003, then you can enable VSS. This will automatically back up every SHARED folder up to 64 versions while running. You can set this to any amount of time. The default is twice daily.

Using VSS coupled with daily backups, should keep you safe. The nice thing about a server/client system with a domain is the permissions. You can set them so that users do not have access to modify the folder, only to read/write. It has been my experience that accidental deletion of files doesn't happen that often.

If you are using a non-server OS such as XP or 2000, You could purchase a Mirra Server from Seagate. This is a standalone server (basically a hard drive except it does contain a built-in OS), which backs up any folder every time a change is made. The problem I have found with the Mirra, at least with the version I have, is you can't set the time interval, therefore it is only helpful if you discover the problem rather quickly.

Vista has VSS built in, so most folders have previous versions. Just make sure it is enabled in Control Panel -> System -> System protection. I believe XP only allows a snapshot of an entire drive and does not make previous versions of individual files and folders available. One good thing about Vista over XP.

I am Leslie, thank you.

Bert mentioned the Mirra Personal Server. I would recommend it.
It performs continuously running backup of the specificed folders. Since it is networked, it will backup any specified folder on any of your networked PC's. It even does a backup everytime a certain file is modified. So if alter a file and save it, then realize you want to revert to prior version of that file, you simply restore that file. I use this system (A Crhistmas present from Bert).

What Operating System is on your server? This would help us determine if you have capacity to set permissions. Permissions would be the best way to prevent staff from frigging up that folder.

Yes, but if you get a Christmas present from me, make sure you hide it and never tell me you aren't using it. Because, like the Cisco PIX I gave Adam, I may be low enough to ask for it back if I see you aren't using it. That's pretty low, but then Adam will tell you I am pretty low.

I am using SB 2003. I will try setting the VSS (which prior to this never knew existed). My most recent and now EX-IT guy was not helpful at all. I had to fix a problem with the server's automatic updates. He didn't even catch that it was still hadn't downloaded SP II !!
I also will look at Mirra personal Server.

Leslie

Leslie,

1. At a run command, type "services.msc" without the quotes. Enter will open the services window. Alternatively, you can access from Administrative Tools --> Services. Make sure the Volume Shadow Copy service is started is on manual mode.
2. Go to My Computer on server. Right click and drive, i.e. C:\ and choose Properties. Select Shadow Copes tab. From there it is rather intuitive. FYI: You can set any drive from within the same window. It makes 64 copies. I generally wouldn't set to less than four hours, but you can.
3. Remember, you do the settings on the entire drive, but you can only make copies of SHARED FOLDERS.
4. FYI: You cannot access the copies from the server. You must access from across the network. So, from any workstation, you can go to My Network Places, browse to the server, browse to the folder, right-click and choose the Previous Versions.
5. Personally, even though Adam does it and I used it, I wouldn't recommend using the Mirra on the server. I can't find any information on it, but I would be concerned that the auto backup of the Mirra would interfere with VSS.

Once, you make sure VSS is enabled by right clicking on a drive on the server (from the server), you can look for previous versions from an XP machine on the network to insure it is working.

This is an added benefit of VSS. VSS is intended to make sure everything is already backed up individually including databases so that when your backup runs at night, it backs up the shadow copies. This is in case it can't backup open or accessed databases during the backup. (A good reason to make sure users log off their computers rather than just lock them when they leave)

Your IT guy can't tell you everything, but why he wouldn't let you know about VSS is beyond me. I would call him and ask if he even knows what VSS is. Make sure he answers before he has time to Google it.

Hope this helps.

Thanks, Bert.
I will work on it this week. My IT guy is no more....I am flying solo (stupid I know.

Leslie

Didn't mean to make it sound that hard. It should take all of three minutes or less.

Jim, we used what Bert suggested above, creating extra "users" with various permissions. Works out well for us - our "insurance card/demographics" employee has "High: mid level provider" status so whatever she scans in does not generate a message to me. We made a user named "Lab" for scanning in labs, test results, stuff docs need to sign off on and set the level of access to low so everything they scan generates a message. We have a user named "Records" for scanning in old records from other docs I want to review. Plus we still have all the MA's with their own sign in names for all the medical issues, refills, etc. I know it kinda sounds like a pain having the extra user names, but the main reason we did that was b/c of the issue you were having - I hated seeing an inbox with 250 items in it all from one user...where do you even start! By having the different users, when I click on the "From" tab, it organizes the messages by user name alphabetically. That way I can ignore the stuff from "Records" until I have some free time and focus on the stuff from my MA like refills etc. or work on my labs from the "Lab" user.

Since we started running version 4, it has gotten easier. You can color code messages now (like red for asap, blue for refills, or whatever), and the sign off process has been streamlined. I still have 200 items in my inbox but thats just b/c I'm wasting time on the web while all those scans from "Records" sit there for a month ;-)

Steve,

Wow! I never knew you could click on the From button. That is a GREAT tip! Thanks.

Oh, just a side on the updox (which would prob be better in a separate thread but...) we tried using this too and it did show promise but we had a problem. My wife and I are the two docs for the practice, and unfortunately, no matter which provider name we picked to be the sign off provider when importing with updox, everything kept going to my wife's inbox...sorta annoyed her! Not sure if that is a know issue or just some type of glitch for us, but we ended up just using the system above. That way my employees can sort out and organize all the crap coming into the office instead of me having to do it.

Hate to admit it but I wasnt smart enough to come up with the "From" button click idea - it was my wife's...I better give her credit in case she reads this someday!

Hello - We convert all incoming fax to pdf and load relevant patient related data into AC. Once the pdfs are in AC, our front-office person forwards the docs to the doctor for sign-off. In AC version 3.7x we were able to select multiple scanned documents (labs etc.,) and sign-off.

After upgrading to 4.0.52 version there does not seem to be the ability to select multiple docs for sign-off. Could someone please let me know if we are not doing something, skipping a screen etc? This is getting to be really annoying.

Thanks

Sekhar
Athens, GA

sekhar,

Sorry, just a question as I am about to start scanning documents into AC....
Do you scan to a file that your staff sorts through? If so, is that file located on your server? I am a bit leary of having the staff play on the server itself....

Thanks in advance

The staff should never "play" on the server. As with your databases, you simply share everything and your users browse to it. You can do this with any computer on your network or with a server that is on your workgroup.

This is one of the very nice things of using a client/server setup on a domain. You can set many access rules for each user using fold permissions and NTFS permissions.

So, share it or map it. To be quite honest, if everything is on the server, then aside from maintenance, no one has to ever be on the server including you.

We figured out what the problem was. After upgrade, selecting multiple docs to sign-off was turned off. We had to turn it back on. That took care it.

As far as scanning documents - all scanned documents go into a folder on the server that is shared. We created a share for the specific purpose. This share sits on all front-office desktops. Front office folks then move it into AC. All this is relatively straight forward - setting up preferences as to where the scanned docs are stored, creating shares etc.,

As Bert suggests as a general rule except sys admin, no one should be physically on the server.


Hope this helps.

Sekhar