Home Forums Discussions Problems Documentation of faxes and front office notes

Aside from writing in the addendum region, does anyone have any ideas of how to better document:

1) faxes, such as notes or records out of ac

2) notes of discussions with the patient from the office, ex, billing/scheduling, not clinical related..

trying not to fill up the addendum area with lots of non clinical stuff

with not clinical related, often we put it in the yellow sticky section if it short, such as will not be seen until brings copay back or transferred out and not allowed back. Other more involved we will do as a note, but this is rare.

Faxes, generally we will save a copy of the release and send out the visit note with a comment in the note section as well.

You can use the comments section when you import a fax ie: discussed with patient importance of taking medication, diet counseling etc. Besides the comments section, we use Updox to mark up the faxes but you certainly can use other programs (paperport etc).

As for discussions regarding billing/scheduling, we usually do these as addendums.

We often send messages back and forth:

Patient Test E. Testing called about his labs. We reviewed his abnormalities.

And then save them to the pt chart after first using the 'attach' button.

Think I can deal with my front staff attaching addendums that they faxed the note on to the bottom....

Not sure how yellow stickies work or if they will be followable in the future.

Faxing labs from quest imports are an issue as well.... Nothing to write on to confirm sending...

Can just suck up and do addendums..will bulk the chart up...


Wish list: non clinical note writing area!

Wish list: non clinical note region.

Neil,

I use Updox in our office. Nice thing about Updox is you can mark up a fax and file it into AC (you can do this with Paperport too). When I send a fax using Updox (faxing labs for example), I also file a copy in the chart under correspondence (all with one click). This way I know what I faxed to a specialist.

For non-clinical, administrative information, we have a Word document titled Administrative Log (a blank page). We import it into AC Imported Items non-medical category for each patient. We then title it with the patient's name. When you need to document an administrative task, just open the document and type the date and needed information. It can be modified just like Excel spreadsheets imported into AC. So, it is a running log of admin tasks. And, since it is non-medical, it requires no sign off.

Good suggestion Donna!

Donna, my staff is very happy with you!

Marty,

Is the "comments" section something that comes up on every fax imported into AC? Or is it just with a separate management system like UpDox? It sounds like you are talking about two (three, if you count Paperport) ways of being able to "mark up" a fax.

Do the markings stay with the fax permanently? (I assume that it remains tied to the pts. chart in the imported items area?)

Thanks,
Melanie

Don't forget acrobat. Marks up the original file.

Currently, when a phone message come in from a patient about something - such as, "Pt. wants a refill of antibiotics" the M.A. documents it on the old-school phone message book log (which saves a carbon duplicate), and clips the message to the paper chart. We write our answer to that "No, need OV if not better" and the chart goes back to the M.A., who calls the patient back, documents the date/time of the call, and tapes the message in the chart.

Keeping the phone messages linked to a pt. chart is obviously necessary for medico-legal reasons.
How are these messages permanently "saved" to a pts. chart in AC? Sticky notes are not permanent, so that can't be used...

Melanie

Are you saying that with Acrobat (is that Acrobat Pro X?) you can annotate the original fax? Is it permanent?

Melanie

My staff documents phone calls as messages in AC. Your MA would send a message to the provider, the provider then writes back his response and sends it back to the MA. The MA can then document what she needs to write and save it to AC. AC keeps track of dates on the messages.

This is a permanent part of the chart if saved.

Thanks, Marty, that is exactly what I wanted to know. So, to be clear - if our pt. Jane Doe calls and asks for a mammogram req., and the staff calls her back and say she hasn't been in in a year and needs a clinical breast exam first, the emails exchanged between the staff and myself documenting this can become a permanent part of her chart, as long as they are saved?

Where in the chart would we look to find it, if we needed to in the future?

Does is get saved as an addendum to her chart, or is it saved somewhere else?

Melanie

As long as the message is saved to the chart you are good. The messages are found in the PAST ENCOUNTERS section of AC

Excellent - thanks!

I could use UpDox, or Paperport, (or Acrobat? - per Sandeep) to permanently annotate documents I receive by fax with the same back-and-forth-messages between staff and M.A.s - and save those as well, right?
I suppose they would then be found in the imported labs area of AC, if needed for future reference?

Melanie

Melanie,

I respectfully suggest you re-read your posts where others have answered your last question.

Thanks Marty. Will do.

Yes. Acrobat Standard works too.

Melanie,

with the click of "to portal and to EHR" you can send the mammogram report with attached or typed up note attached to mammogram that is sent permanently to the AC record and instantaneously through encrypted HIPAA compliant portal--works slick!!! the patient if on line can access the info right away, and you save a stamp and envelope and the time it takes your staff to do that--

Thanks Jimmie! Are you using UpDox to do that, or just AC itself?

I am sitting here imagining the time saved by sending results by email. Our M.A.s have stacks of "callbacks", then smaller stacks of callbacks to people they called that were not home, etc. etc. They spend hours each day doing nothing but this, playing "phone tag" with pts.,and taking messages...

Melanie

Melanie,
both updox with AC--and not technically emailing--as emailing connotes non HIPAA transmission of info, the only time i email is to send a patient a notice to the portal and since the portal is password protected on both ends and uses encrypted messaging is HIPAA compliant so I have trained my nurse and myself to use the term "secure messaging" instead of "emailing"
It has been a tremendous time saver and if the patient does not open the message in a week my nurse gets a message and then sends them a reminder on how to utilize the portal by mail, and once folks are trained it is quite the time saver, initially some upfront extra work for the nurse but a time saver in the long run.

Melanie,
I should have added that the secure messaging is more efficient and quicker than voice mail in my opinion--my nurse copies and pastes the messages from updox to AC to send a message to me and make part of permanent record, with voice mail she has to type and send.
Plus the computer is visible and she keeps the updox screen open and in real time is glaring right at her to get it done.
Also older patients who don't feel comfortable with computer i get signed okay from kids to recieve their info via portal which has been helpful, and the dreadful two page medicare assessment form we have been mandated to do as of JAN 1st if we bill out a medicare wellness exam I have available by portal as well as med refills, script refills and demographic form to fill out, which helps with efficiency.
On the other end when I send out the summary my wife has typed up attached handouts for all the health maintenance stuff like exercise diet alcohol use smoking etc. which my nurse based on my summary will attach as needed--

Jimmie,

Good point about the term "email"!

I know you are now using UpDox - what, if any, is the advantage to using UpDox vs. just AC in this particular process?

Melanie

They ARE dreadful, aren't they! As it is, I have an M.A. sit there and ask the pts. the questions (it's a huge waste of my time to do this). If there is a way to train those pts. to fill out their part of the form ahead of time, that would be great.

Heck, I'd be happy if we could just train new pts. to fill out their registration forms online before they come in! A new pt. with an 11:00 appt. invariably comes in at 10:55 AM, and still has to sit in the office and fill out the forms, etc.

Small wonder we run behind so often!

Melanie

In my opinion the two have to be used together and I could not do what I am doing without both, and both play extremely well together, but I have only been doing this since November and I get nervous just hooking up my scanner to my computer. so with that being said the two systems together work well for a computer phobic internist that has only the rudimentary understanding of computers and the additional software and hardware that goes with all this stuff.
However I am amazed at the functionality, improved efficiency in my office and my monthly charges are up 20%-- that I will likely only apply for the meaningless use stages to avoid any penalties and could really give a rats behind at this point chasing after 18 grand I may never see, and with my improved efficiency may be better continuing to focus on improved efficiencies. I figure the postage alone saved by the updox portal will more than pay for itself over time. I don't want to sound arrogant or belittle anyone going after the 18 grand for stage 1, this is how i feel right now, and may change my mind because if i could do it without too much difficulty I will. 18 grand my 30% for taxes is nothing to sneeze at, I just don't want to lose the ability to maximize my efficiency in the office chasing after a carrot thaqt may choke the rabbit.

Jimmie, congrats! No one could ask for a greater testament to AC and Updox (and to your efforts). MU or not (and Dave Grauman, among others, would certainly support your decision), it sounds like you are really successful.

It's likely more around 15-20% (the charges) fairly consistent the last 3 months--and the overhead has stayed about the same except for the cost of AC plus offsite backup 2 laptops, a scanner, a new printer, encrypted wifi router I think all about 6 grand, so if i could get three more items on my stage 1 meaningful use and get the 18K this would offset these costs-- --so my overhead spread out over 6 months would be about 1000 dollars more per month, but the point that has amazed me is the ability to capture the work in which I do--I am doing many more wellness visit with a 25 modifier often with a 99213 because of complexity of problems with most patients and have been able to justify more 99214's with the better documentation--so in essence capturing the work i have been doing all along, but just more able to reflect in my notes now than ever before-- as i see it. It has not been without busting my arse and a lot of late nights and weekends to get the initial data entry in though.
thanks for the congrats, and I can't say enough to you personally jon for all your help along the way and i hope you will let me bend your ear in the future too--