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ABILITY TO SIGN OFF ON LABS AND PT REPORTS

Huge Liability that we dont have a holding area for uploaded documents from labs, other physicians and diagnostic reports. In a paper world, we are required to view and document we have seen the report. Now any staff can upload these documents, but there is no notification to the physician that its there. Meaning important results, and documents can be missed.

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    Peter UzelacPeter Uzelac shared this idea  ·   ·  Flag idea as inappropriate…  ·  Admin →

    12 comments

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      • Anonymous commented  ·   ·  Flag as inappropriate

        Under the "task" section on the ipad, there is an "edit" feature on the upper right. If you choose that, the document pops up, and you can free draw, add text dialogue. I use this to sign off on incoming documents via the ipad, then "save changes" down on the bottom right once completed. These are permenant edits to the document. There is also a log of when it is looked at assigned to the user. So there is an electronic date and time assigned to you every time you look at it automatically.

      • Alison BhattacharyyaAlison Bhattacharyya commented  ·   ·  Flag as inappropriate

        If you could add the ability to date/time stamp, and add a comment, that would appear on the document itself that would go a long way to solving this problem. We use Updox to do this. Everything that needs to be reviewed by a provider goes through Updox, and it can date/time stamp, initial and put in comments. It stamps the information on the .pdf directly. Anything that needs follow up can be added to a task list.

      • Kim SetserKim Setser commented  ·   ·  Flag as inappropriate

        Definitely a liability risk not having these items "signed" when viewed by the provider.

      • CindyCindy commented  ·   ·  Flag as inappropriate

        The ability to mark an uploaded document as "need to be reviewed" is something we require as well. Only 2 of our lab companies can integrate with Chrono. That leaves us having to upload the remainder of the labs into chrono as pdf files. There seems to be no way for the nursing staff or provider to review these labs that are uploaded as documents.

        As well, there is no good way for our admin staff to notify the nursing staff that a lab uploaded as a document needs to be reviewed.

      • Anonymous commented  ·   ·  Flag as inappropriate

        If that is being added It really should have a place for notes that the doctor needs on that report and a signature. (i.e. if he changes a dose of med based on the lab that needs to be attached to that lab report and be seen when viewing that lab again.)

      • Dan LandmannDan Landmann commented  ·   ·  Flag as inappropriate

        I agree - a common work flow is that we get a pathology report back. My office manager assigns it to the patient chart, but then I have to look at it. If it were on paper, I would just sign it and scribble something to the effect of, "Discussed with patient".. or "schedule surgery".. so the ability to annotate documents would be very helpful.

      • Uday Khosla, MDUday Khosla, MD commented  ·   ·  Flag as inappropriate

        I agree - this is a problem - we get many patient documents daily - how are we supposed to know they are there? There has to be a notification on the front screen that states that there are "unreviewed" documents that require our review. When done, we can 'sign off' on them indicating we reviewed them.

        IDEALLY, we could annotate that document and digitally sign it and THEN re-send it via email or fax.

      • Anonymous commented  ·   ·  Flag as inappropriate

        I agree with the liability issue
        the uploaded forms should not be filled without an electronic signature
        one alternative is to place the document under the status of unlocked notes
        which will be pulled out with the unlocked charts

      • Anonymous commented  ·   ·  Flag as inappropriate

        In our office, documents are received in the computer in the New Message List via fax from other entities. Our Dr. reviews them before sending them as a task to appropriate office staff with her comments attached. The office staff then processes the document (i.e. call lab results to pt, calls refill in to pharmacy, etc) then attaches the document to the chart. Using Dr Chrono in this manner ensures that all documents are reviewed by the physician first. Any paper documents received via mail or paper fax are placed in an "in basket" for physician review. She makes her notations on the document and places it in an "out basket". We upload the document after taking the appropriate action based on her notation. Both of these processes ensure the physician reviews each document before it is uploaded to the pt chart.

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