Using Document Capture to Scan Client Documents

Overview

Telecare’s Avatar’s Document Capture functionality is used to scan paper documentation related to a patient’s treatment and attach it to an episode of care. Scanning documents into Avatar can happen during the treatment process or after discharge. If scanning after an episode of care, once the patient has been discharged, the entire paper chart (Batch scanning) may be scanned into Avatar which becomes part of their permanent electronic medical record. Once the paper chart is scanned into Avatar the paper copy may be shredded per the document retention policy.

Preparing Your Document(s) for Scanning

Overview

Each original Telecare document should be visually inspected to ensure that the image is complete, clear and usable. Scanned documents should be compared to the original paper document to ensure accuracy.

The number of original paper documents must be compared to the number of scanned records to ensure that every document was scanned.

Step 1: Prep the record.

This step not only ensures that the record passes smoothly through the scanner, but it also helps enhance data integrity.

• Ensure that all documents belong in the correct patient medical record.

• Verify whether the patient identifier is correct and consistent on every page.

• Ensure that all documents are part of the required FFS documentation packet.

• Remove all staples.

• Smooth the documents so they don’t include any folds or wrinkles.

• Ensure that no documents are stuck together.

• Use caution when separating or tearing documents apart.

• If possible, ensure that all documents follow a clear chronological/sequential order, this is particularly true for flow sheets.

• Do not use Highlighters on any original documents, they will appear black when scanned.

Step 2: Index the record.

Index documents according to their specific naming convention. (Appendix B)

• Confirm that the identity of the client listed in the paper documents corresponds with the identity of the client in Avatar.

• Validate to ensure correct client name, medical record number, DOB, admission and/or discharge date.

• Be consistent in your selection of the correct scanning category and document information.

Step 3: Scan the document.

This phase includes the actual scanning of the documents and requires strict attention to detail.

All Telecare documents scanned MUST be originals.

• If scanning multiple pages, fan through the documents to ensure that no staples are stuck between the pages.

• Begin the scanning process. Keep your eyes on the screen to monitor the quality of the scanned imagine.

• If a line appears on the scanned image, stop scanning and clean the glass of the scanner.

• Ensure that you have selected the correct Avatar scanning category.

• Each document scanned MUST include the proper Naming Convention (Appendix A)

Step 4: QA the record

• This step provides an opportunity to catch errors and improve processes going forward.

• During the QA process, validate to ensure correct client name, medical record number, DOB, admission and/or discharge date.

• Ensure that the information is consistent on all remaining documents by viewing every page.

• View the document to ensure all information was scanned properly.

• Re-scan and/or Re-index any documents, as needed.

• Carefully, stamp the documents, which should include the date at the bottom of each page.

• Do not stamp over any documentation, in the event the documents must be rescanned.

Please remember that these scanned documents will become our legal clinical record, when the originals are destroyed.

How to Scan Documents into Avatar

Methods of Scanning

Documents may be scanned or imported from an existing PDF file to a patient’s episode of care. Paper documents can either be scanned immediately as individual pages (Point of Scanning - POS) or in pre-organized batched files. This document will address Point of Service (POS) scanning.

NOTE: POS scanning allows only one category to be scanned at a time.  If scanning an entire chart with multiple categories of documentation; (i.e. Admission, assessment’s, treatment plans, etc.), you must use the Batch Scanning and Indexing process.  See Avatar Batch Scanning documentation for full details on batching scanning.

Scanning the Document

Open

Click on Document Capture

Navigate to the client’s chart view by clicking on the client’s name twice. 

On the left side of the client chart, Click on Document Capture.

NOTE: Document Capture/Scanning must be started from the Client’s Chart View.

This will open a message window for you to select “How you would like to capture document?”

Open

1. Scan – Scan a document using the scanner.

2. Import a document already scanned but not attached to a client record.  (Previously created PDF file)

3. Cancel the process.

Click Scan to begin the scanning process.

Select the appropriate Episode of care to associate the documents to be scanned. 

This will open the Document Capture window.

1. Click the Capture button or;

2.  click the scan image in the middle of the Document Capture screen.

NOTE: Place the paper document(s) in the scanner prior to scanning, the scanner will automatically begin scanning all pages once the Capture button is clicked.

Once the scanner has completed scanning all pages, an image of each page will appear. 

QA the Scanned Record

The Document Capture window has several features to help with reviewing the scanned document.  This is to ensure all pages were scanned and legible prior to saving the document to Avatar.

1. Capture, Save, and Reset Buttons

2. Thumb Nail view of pages.

3. Scanned Document preview

4. Icons to turn thumb nail view on/off and image scanner Settings.

5. Document Properties:

6. Client – Verify correct client.

7. Episode – verify correct episode of care.

8. System Code – will default to user’s program code.

9. Document type – Select the appropriate Category. See Appendix A

10. Document Date – Enter Date of Document

11. Document Description – Use appropriate Naming Convention.  See Appendix B

12. Icons to Rotate document 90 degrees left or right.

13. Delete page.

14. Navigate through scanned pages.

15. Page Zoom

16. Adjust view size.

(1) Click Save - before saving verify all pages were scanned and all documents are legible. 

After submission, the system returns you to the beginning of the Document Capture screen. Two green labels replace the image, one for Save was successful, and one for Document Added to Avatar.

Click on the (1) Stop sign to close the Client Chart view and exit the Document Capture window.

(2) Documents may be viewed from the Documents listed on the Chart View.

NOTE: Imaged documents may also be viewed through the Clinical Document Viewer.  See instruction manual for details on how to use this form.

How to Import Documents into Avatar

1. Navigate to a client’s Chart View.

2. Click the Document Capture link.

5. When the message displays, “How would you like to capture documents?” click Import.

6. Select the appropriate episode from the Episode Number drop-down list and select OK.

7. Select Capture on the Document Capture screen.

8. This will open a Select Files screen.

1. Click on the Browse to search for the document you wish to import. You can also drag it to the blue section from your file browser.

Once you have selected a document to import the screen will indicate you have “1 file selected”.

2. Click Done to complete the import.

QA the Imported Record

1. The image displays in the Document Capture screen.

2. Select the correct document type from the Document Type drop- down list, located on the right side of the chart.

3. Update the Document Date to the Date on the Document

4. Update the Document Description - Use appropriate Naming Convention.  See Appendix B

5. Click Save

NOTE: A PDF file may contain one or pages.  Delete any pages that are not intended to be part of the permanent file.

VOIDING a Document: If a document was accidently scanned into the wrong chart, it may be deleted before it is permanently saved using the “Reset” button, otherwise it must be voided using the Clinical Document Viewer.  See Clinical Document Viewer section for details.

After submission, the system returns you to the beginning of the Document Capture screen. Two green labels should appear; Save was successful, and Document Added to Avatar.

This is the confirmation the document was successfully saved to Avatar and concludes the scanning process.

Reviewing your work

After the scanning process is completed a Document Category will display with the name of the Document Type(s) you selected during the scanning process.

To Review your work, click on the Category to see the list of available documents.  It may contain more then what you scanned.

See Appendix A for a list of approved Categories.

Document Description is Critical. Please use the Naming Convention in Appendix B for guidance.

Clinical Document Viewer

What is the Clinical Document Viewer?

This form lets the user search for and view scanned documents in Avatar. The form provides various criteria for filtering the results.

Using the Document Viewer Form

Search Criteria Tab

Open the Avatar Form: Clinical Document Viewer.

1. Search Window: Select specific Criteria to limit results.

2. Results Window: Displays all results based on Search Criteria

3. Select Type: Select Client or Staff

4. Select All or Individual Client: Select All to search by program; select Individual to search by client or staff name.

5. Select Client: Enter Name

6. Program: Select one or more program

7. Episode: Select episode of care

8. User: Enter Name

9. Document Status: Select one, leave blank to view all.

10. Document Source: Select one or more, leave blank to display more results.

11. Document Origination Date: Search within a date range

12. Form Selection: Select One choice, these will only be useful if documents were scanned according to Document Type

13. Form Restrictions: Some forms are restricted.  Select “Include” for all three options to view all scanned docs.

14. Click Ok and Process or Close

Search Results Tab

The Results window has to areas:

1. Tree view – displays folders and files of all scanned documents.

2. Document List: Displays the following information for each document:

• View/Print Check Box: Use this to select multiple documents to view or print at the same time.

• Client ID

• Client Name

• Episode: Episodic or Non-Episodic.

• Linked Record: Currently not using.

• Document Description: This is the Note Field from the ImageNow Viewer window.

• Document Date: Date document was scanned.

• Document Status: Final or Void.

• User: Avatar user who scanned the document.

• Do Not Release: Currently not used.

 Viewing a Document

1. Once a Search has been processed, the results tree will be enabled. Click on the arrows next to the folders to expand the view and search for documents saved within that folder. A document may be opened from the Results tree by clicking on it.

2. Documents will be displayed in the view window; allowing the user to verify they have selected the correct document. Use the navigation buttons in the upper right-hand corner to move through the pages or rotate a page.

3. All opened documents will be listed on the Document List Bar. Clicking the ‘x’ will close the individual document.

4. Use the buttons at the bottom of the screen to

5. Print, Void and/or Close All Documents.

Administrative Functions

Clinical Document Viewer and Managing Scanned Documents

This section will cover how to void documents and make corrections (i.e. moving a document from an incorrect episode or client to the correct episode or client) with Clinical Document Viewer in Avatar.

NOTE: Only staff with admin-level document management access in Avatar may use the Void function.

Accessing the Clinical Document Viewer

Type Clinical Document into the Search Forms field.

Double click on the Clinical Document Viewer to select and open the form.

Searching for Documents

Before you can void or move a document, you must search for it. Please note the search tab on this form only has 2 required fields, however, the more fields you fill out, the more likely you are to locate what you are looking for.

1. Select Type - This will default to "Client" and as of this time, there is no need to change this selection.

2. Select All or Individual Client - For the purpose of searching documents to void, your selection here should usually be "Individual." Please note that two fields will become red and required with this selection ("Select Client" and "Episode")

3. Select Client - If you selected "Individual," you may search for a client. Double-click on the client once you've found them to insert them into the field.

4. Program – If All was selected, Select the program.

5. Episode – If Client was selected, select the episode where the documents are located.  Selecting "All" will return more results.

6. Select Final or Void, selecting neither will default to both.

7. Select a Document Source to filter out scanned forms.  Selecting nothing will default all sources.

8. Form Selection – Select Entire Chart to see all results

9. Form Restrictions – Select “Include” for all three options.  This will display all documents.  Some documents may be excluded by default.

10. Click Process to find the document.

Document Viewer Search Results

After you click "Process," you will be brought to the Results tab to show the results of your search. On the left side of this screen, you will see the categories of those results and have the ability to click on the folders to open them and to drill down further.

The actual documents of the search will be shown in the large space in the middle:

The columns will provide more details on the document itself. Use that information to identify the document you want to void, then click on the row for that document to select it.

Voiding and moving a Scanned Document

Once a document has been selected, the image will appear in the main part of the Avatar screen. If there are multiple pages in the scan, page 1 will appear, and the other pages can be viewed by clicking on them on the left-side of the main image screen.

Verify this is the document you want before voiding – if it is not, click the "Close All Documents" button near the bottom to select another document. If this is the document you want, click the "Void" button near the bottom to bring up the fields to void and move.

Once you click Void, a window will appear at the bottom with options.

Void or Void & Copy

The Void window has two (2) option for managing a scanned document.

Void - this will void the document from the official client record and also from the view of anyone that isn't a Document Management Admin. You can still view these documents after a void, but the Document Status will reflect a void status.

Void & Copy - this may be used to move documents either from an incorrect episode to the correct episode of care, or a document from an incorrect client to the correct client.

Void a Document

1. Select Void

2. Select a Void Reason of Poor Image, Rescan on File

3. Enter Void Comment

4. Click Void to complete the process

Void & Move a Document to another episode of care or different client chart.

Fields in Red are required.

1. Select Void & Copy

2. Select Client – select the client; select either the client and correct episode of care the document needs to be moved to or the correct client name the document should have been scanned too originally. 

3. Date – Enter the date

4. Select Episode of Care – Select the correct episode of care this document belongs in

5. Select a Void Reason of Incorrect Client Chart

6. Void Comments - open text field; you can explain your reasons for voiding further for auditing purposes

7. Form Type – Select the Category this document belongs in

8. Change Description – the description will auto-populate in this field.  Modify the description if required.

9. Click Void to complete the process

Click Cancel Void to exit the Void Screen.

Verify Change

When finished, verify the document has been voided.  A "Void" status will display in the Result table from the Clinical Document Viewer.  If moving a document, initiate a new form/document search to verify it shows in the correct client episode.

Scanner Report

The Scanned Docs Multi-Program Report provides a printout of all scanned documents.  It can be filter on Program(s), Start and End Dates and by form Categories.  You may also sort the results by Admit Date, Scanned Date and Scanned By.

Report Example

APPENDIX A

Scanning Categories

• Acknowledgements/Consents/Legal

• Admission Documents

• Assessments

• County/State/Federal documents

• Discharge Documents

• Financial Eligibility

• Mars/Labs/Testing Results

• Miscellaneous/ Outside records*

• Nursing/Flowsheets

• Physicians Orders

• Physicians/Medical

• Progress Notes/Observations

• Referral Documents

• Seclusions & Restraints

• Treatment plans

*Categories in red are not included in Disclosure packets.

APPENDIX B

Document Category Matrix

ALL DOCUMENTS PROVDED DURING THE SHIFT - MUST BE SCANNED BY CLOSE OF BUSINESS