Home Forums Attaching message to patient chart

Ok, Hos do I attach a message to a patient chart for documentation... suchas.... patient needs MRI/MRA of head
for tia/memory loss. I send message to staff to address.
They complete and send me back the message. How do I attach this to the patient chart.

Click the button "Save to Chart" in the right lower margin of the message window, with the message that you want to save open. You will then get a confirmation dialogue box "Do you want to save this message to the patients chart?", and then a second box asking whether you want to delete the message (after saving) from your email inbox.

To retrieve a saved message, look under the "Past Encounters" tab, with the patient's chart open.

John,

Do I find this Save to Chart on the original message? When I receive the message back with a response, I am not finding that Save to chart in the message window.

Jennifer,

The Save to Chart button is always there. It never goes away. As long as the message is highlighted and therefore present as a message with all of the patient information in the bar next to the red paperclip, then on the right, you will always see the following from top to bottom:

Refill Meds
Pull Chart
Save to Chart

I am not sure how you are missing that. From what you wrote, it sounds as if you are looking IN the message window rather than to the right of it.

We run into trouble when the physician wishes to save a message he is -currently writing- within AC to a patient's chart. Meaning, he types up his message, selects a patient to attach, attaches the patient, and then he can click "Save to Chart," which will save his message to the chart, but delete the message at the same time. This is a problem because the message has been saved to the patient's chart, but the message was never sent to the recipient!

It would be nice if we could just send the message, go into the Outbox, select the message and click "Save to Chart" from there, but the "Save to Chart" button is not available through the outbox.

What I have recommended is if the physician is typing a message that he wants to immediately save to the patient's chart, and send to a staff member, he should CC himself, so that the message appears in the recipients box and his own. He can then open the message within the inbox, and save it from there.

There is also the option of "Retrieving the Message" but this removes the message from the inbox of whomever received the message in the first place.

I guess I am not quite understanding the issue. You are quite right that if you need to save a message and send it to someone, that you have to CC it to yourself.

I am not sure why you want to send it to someone and save it to the chart. I mean I can understand it for documentation purposes, but that has never been the way AC has been set up. Generally, messages are sent to other staff, they do something and document what they did and either save it to the chart or send it back in which case you have the same two choices.

Given that unlike email, there is no Sent folder, there is no real audit trail of messages you send. So, I can see where there may be times that a message sent is so important, you want a record of it. Therefore you can CC it to yourself.

Maybe it isn't a bad idea to be able to have a button that does both. There is already one scenario that seems to show the method is in place. When you receive messages from staff and reply, it asks you if you want to delete the old message from your in box. Maybe when you save it to the chart, it could give you a message to see if you want to delete or send the message.

Bert, I think this may have something to do with how much you can depend on your staff. If I send a message to a staff member, I have to assume that 1.they do it, and 2.they document it by sending a message back to me so I can save it to the chart.
If the staff member doesn't do this, I have no record of having asked, and my feeble mind will likely forget it. At least if I can message the staff and save the message, I know I did my part in making the request and my intent was documented.

I agree. But, in some ways it is just as important for the staff to do the same thing. Say I send a message to my MA asking her to call Mr. Coagulopathy to decrease his Coumadin. While she could do that and document it and save to chart, she may just as likely document that she called the patient, gave him the message and he understood. Now, I should save that to the chart, but I screw up and delete it. Now, the MA has no documentation. Maybe the conversation should be documented as it is going along in the patient's chart? Or all messages could be auto saved to a folder on the server. Just some ideas. It's a tough one.

Yes, and I agree with you- it is important for the MA to be able to do the same thing. So in your example, the staff member should do the task and message you back that it is done...at the same time, she should be able to save the message to the chart. Same thing as what I want to be able to do when I message him/her.
This is basically a replacement for my past practice of scribbling a note at the bottom of the lab or x-ray report to call the patient (or whatever)... and she scribbles "done". In the old days, those scribbles were in the chart. I think they belong there.

Totally agreed. I wish some of these small things could be implemented. Unfortunately, the government's requirements on everything is taking up the developers' time.

When you send the message to the MA " call Mr. Coagulopathy" and the MA then does so recording the contact in her message and the saving to the chart it is the exact equivalent of what used to happen with the paper chart. " call Mr. So and SO, needs to up the coumadin" initials/date, "done" initials/date.
The "missing" part is whether or not you see the chart again after the patient was contacted. Myself, I expect those tasks to be completed and don't want to double check the chart, I trust them to put the chart back into the file cabinet as it were.
Alternatively, if you send the task to them as an order, the new "view orders" tracking function of version 5 allows you to monitor open orders, results pending and completed orders.

I like that as well. And, I think comparing to paper charts tends to be a good idea.