Health Informatics

1.  What is the process of scanning or creating documents at the point of care

Posted 03-07-2015 19:53
This message has been cross posted to the following Discussions: Health Informatics and Health Information Technologies and Processes .
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Please correct me if I am wrong, but I think this is the correct order:

Created at the point of care documents:

PROCEDURE/OPERATIVE SECTION

Procedure/Operative reports

Surgical Pathology Report     

Operating Room/L&D charge           

Pre-op Questionnaire/Instructions     

Verification of Surgical Procedure and Surgical Site                                                

Surgical Consent/Consent for Treatment

TREATMENT SECTION

Respiratory care

Physical Therapy                    

Occupational Therapy

Speech Pathology

Recreational Therapy

RESTRAINTS AND SECLUSION

Seclusion/Restraint Order Form

PATIENT EDUCATION

Teaching-all nursing

Dsch/Teach/Sum

NURSES STATION

Nursing Admission Assessments: Vital Signs Record, I & O record, Diabetic Record        ,Medication Records (daily & weekly)                    

Clothing and Valuables, and AMA Forms

 

 

 

Scanned at the point of care documents:

ADMITTING INFO            

Inpatient Admission Registration sheet

Conditions of Admission                   

Code Status Orders               

Medication Consents

ADVANCE DIRECTIVES

Advance Directive

Transfusion                                        

Inter-facility transfer sheet                

Death Notice

Death Certificate Worksheet

Autopsy

 PREADMIT SECTION

Emergency Department Registration Sheet

Pre-hospital care report (Medical Transportation)     

 H&P/

MD PROGRESS NOTES                           

 LAB

RADIOLOGY

Angiography, CT scans, Diagnostic Imaging/X-Rays (Mount 1/2 sheets on blue forms), MRI, Myelogram, Nuclear Medicine(6025), Ultrasound

DR. ORDERS

 

 



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Elena Krivko
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2.  RE: What is the process of scanning or creating documents at the point of care

Posted 9 days ago
Hi,
We are trying to see what best practices are for scanning at the point of care. Specifically our Consent to Treatment forms. Are these being sent to HIM or are the registration folks scanning at the point of signature?  I would like to know what others are doing?

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Erika Howard, RHIA, CHPS, CHTS-IS
President
Www.emrcsonline.com
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3.  RE: What is the process of scanning or creating documents at the point of care

Posted 8 days ago
Hi Erika,

I work for an organization that scans primarily in the HIM dept. Our registrations areas do scan certain information that is presented at registration which includes consents. The floors do not do any scanning at the point of care but we using a system that most documentation is done electronically.

I hope this helps


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Tamika Smith
Informatics Management Director

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4.  RE: What is the process of scanning or creating documents at the point of care

Posted 5 days ago
We implemented scanning at the point of care for these documents.  There was some concern with them being lost in transport to the HIM department.

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DeAnn Tucker
Privacy & Security Officer
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5.  RE: What is the process of scanning or creating documents at the point of care

Posted 3 days ago
I work in the HIM Department at a hospital and most of our consents are electronic. They are signed and cold-fed in the electronic medical record once the patient is admitted. Surgery consents are not electronic and get sent to the HIM department for scanning. 


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Mayra Posada
HIM Supervisor
West Calcasieu Cameron Hospital
701 Cypress Street
Sulphur, Louisiana 70663
337-488-9369 cell
337-527-4113 office





6.  RE: What is the process of scanning or creating documents at the point of care

Posted 9 days ago
​At the facility where I worked the HIM department oversaw the majority of the scanning. At our hospital is was more efficient to have HIM scan in all documents including consents. The nursing staff had a procedural checklist which would verify that consents had been signed by patient and physician before surgery took place. These documents would then be picked up on a daily basis by HIM and scanned into the chart. We had a smaller 106 bed hospital and did not use batch scanning. Because of the frequent rotation of the clinical staff, the HIM Director preferred to have HIM staff scan to ensure proper placement of the various documents. I believe it is a personal preference that can be decided between HIM and Clinical Operations or management.

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Staci Novelli
HIM Tech
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