Guest guest Posted April 13, 2012 Report Share Posted April 13, 2012 Our EMR files it by patient. So I would likely create a file folder for each patient. And then add sub-folders (lab, radiology, consults, hospital, outside records, admin, billing, etc), and title each document by date and what it is (e.g., 4/13/12 chem for a Chem panel done today). Pratt Hello all,Is there some best practice for filing documents. I am fairly inconsistent in my approach to it and would like some guidelines. I want to be able to look at the list of documents and be able to say what it is by looking at its name. so the name would have some indication of patient identity, date, test/report/issue, normal abnormal.So far I havent done a good job of it, mostly because I dont stick to any particular pattern. What do you all do? Sangeetha Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 13, 2012 Report Share Posted April 13, 2012 Ours does too name/ type of document , but i want a finer level of detail in the NAME of the document itself so when I look down a list of documents , it gives me an idea of " pertinent positives and negatives " Sangeetha Our EMR files it by patient. So I would likely create a file folder for each patient. And then add sub-folders (lab, radiology, consults, hospital, outside records, admin, billing, etc), and title each document by date and what it is (e.g., 4/13/12 chem for a Chem panel done today). Pratt Hello all,Is there some best practice for filing documents. I am fairly inconsistent in my approach to it and would like some guidelines. I want to be able to look at the list of documents and be able to say what it is by looking at its name. so the name would have some indication of patient identity, date, test/report/issue, normal abnormal.So far I havent done a good job of it, mostly because I dont stick to any particular pattern. What do you all do? Sangeetha Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 13, 2012 Report Share Posted April 13, 2012 Are we talking about things you scan in? I can link it to the emr but have never done so I just do it by name and date and topic eg Antonucci,psych eval 3-12. or Antonucci, psych eval f/u 412 so that it is easily searchable and useful as I am working. If it is a consultant note and has a lab or xray in it, my approach is to make a note and say SEE SCAN-so that someone know to go look that there is a document and I say seen by psych/ct brain nl begun on risperdol then my emr puts the lab value( here I mean Xr ) into the lab book and the med into the med lsit. and I can always call up the document by name if Ineed to see itIt is a very good system but it is stupid becasue I have to do work to manage papers and info that should be easier if we all had one emr. Jean Our EMR files it by patient. So I would likely create a file folder for each patient. And then add sub-folders (lab, radiology, consults, hospital, outside records, admin, billing, etc), and title each document by date and what it is (e.g., 4/13/12 chem for a Chem panel done today). Pratt Hello all,Is there some best practice for filing documents. I am fairly inconsistent in my approach to it and would like some guidelines. I want to be able to look at the list of documents and be able to say what it is by looking at its name. so the name would have some indication of patient identity, date, test/report/issue, normal abnormal.So far I havent done a good job of it, mostly because I dont stick to any particular pattern. What do you all do? Sangeetha -- MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 13, 2012 Report Share Posted April 13, 2012 I don’t think best practices exist. IT is a matter of coming up with a procedure and stick to it. My recommendation is- Patient initials- Date- Type of document need some detail for it but don’t overdo it- Result (if necessary) Example MJ-04122012-CRX-N Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php From: [mailto: ] On Behalf Of Sangeetha MurthySent: Friday, April 13, 2012 10:48 AMTo: Subject: Re: document filing Ours does too name/ type of document , but i want a finer level of detail in the NAME of the document itself so when I look down a list of documents , it gives me an idea of " pertinent positives and negatives " Sangeetha Our EMR files it by patient. So I would likely create a file folder for each patient. And then add sub-folders (lab, radiology, consults, hospital, outside records, admin, billing, etc), and title each document by date and what it is (e.g., 4/13/12 chem for a Chem panel done today). Pratt Hello all, Is there some best practice for filing documents. I am fairly inconsistent in my approach to it and would like some guidelines. I want to be able to look at the list of documents and be able to say what it is by looking at its name. so the name would have some indication of patient identity, date, test/report/issue, normal abnormal. So far I havent done a good job of it, mostly because I dont stick to any particular pattern. What do you all do?Sangeetha Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 13, 2012 Report Share Posted April 13, 2012 Thats what I do too.. mur, san, date, therapy shoulder rimprovedOR doe , jan 3/2012 cardiac stress test nml filed into the patients's chart, under, whatever category, but the name now gives me all the info I need at a glance even when I print it out The last part is key, so then I dont have to open the document, to see the conclusion.I was just thinking, surely somebody is doing something better than that? Sangeetha Are we talking about things you scan in? I can link it to the emr but have never done so I just do it by name and date and topic eg Antonucci,psych eval 3-12. or Antonucci, psych eval f/u 412 so that it is easily searchable and useful as I am working. If it is a consultant note and has a lab or xray in it, my approach is to make a note and say SEE SCAN-so that someone know to go look that there is a document and I say seen by psych/ct brain nl begun on risperdol then my emr puts the lab value( here I mean Xr ) into the lab book and the med into the med lsit. and I can always call up the document by name if Ineed to see itIt is a very good system but it is stupid becasue I have to do work to manage papers and info that should be easier if we all had one emr. Jean Our EMR files it by patient. So I would likely create a file folder for each patient. And then add sub-folders (lab, radiology, consults, hospital, outside records, admin, billing, etc), and title each document by date and what it is (e.g., 4/13/12 chem for a Chem panel done today). Pratt Hello all,Is there some best practice for filing documents. I am fairly inconsistent in my approach to it and would like some guidelines. I want to be able to look at the list of documents and be able to say what it is by looking at its name. so the name would have some indication of patient identity, date, test/report/issue, normal abnormal.So far I havent done a good job of it, mostly because I dont stick to any particular pattern. What do you all do? Sangeetha -- MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 13, 2012 Report Share Posted April 13, 2012 Nice, yes sticking to it is what I am having problems with :(Sangeetha I don’t think best practices exist. IT is a matter of coming up with a procedure and stick to it. My recommendation is - Patient initials - Date - Type of document need some detail for it but don’t overdo it - Result (if necessary) Example MJ-04122012-CRX-N Izquierdo-Porrera MD PhD Executive Director & Co-founderCare for Your Health, Inc Phone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php From: [mailto: ] On Behalf Of Sangeetha Murthy Sent: Friday, April 13, 2012 10:48 AMTo: Subject: Re: document filing Ours does too name/ type of document , but i want a finer level of detail in the NAME of the document itself so when I look down a list of documents , it gives me an idea of " pertinent positives and negatives " Sangeetha Our EMR files it by patient. So I would likely create a file folder for each patient. And then add sub-folders (lab, radiology, consults, hospital, outside records, admin, billing, etc), and title each document by date and what it is (e.g., 4/13/12 chem for a Chem panel done today). Pratt Hello all, Is there some best practice for filing documents. I am fairly inconsistent in my approach to it and would like some guidelines. I want to be able to look at the list of documents and be able to say what it is by looking at its name. so the name would have some indication of patient identity, date, test/report/issue, normal abnormal. So far I havent done a good job of it, mostly because I dont stick to any particular pattern. What do you all do?Sangeetha Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 13, 2012 Report Share Posted April 13, 2012 Our EMR has a flag for abnormal, so we don't have to put that in the title. But can't you just use " a " for abnormal and " n " for normal? I would come up with a " key " of abbreviations and print it out and put it on my desk to refer to. If it is filed to the patient's chart, why are you putting the patient name on it? If you have to scan and then import it into the chart, I think I would create folders for each patient and scan to that fold before importing....without putting the name in the title of the document. Pratt Thats what I do too.. mur, san, date, therapy shoulder rimprovedOR doe , jan 3/2012 cardiac stress test nml filed into the patients's chart, under, whatever category, but the name now gives me all the info I need at a glance even when I print it out The last part is key, so then I dont have to open the document, to see the conclusion.I was just thinking, surely somebody is doing something better than that? Sangeetha Are we talking about things you scan in? I can link it to the emr but have never done so I just do it by name and date and topic eg Antonucci,psych eval 3-12. or Antonucci, psych eval f/u 412 so that it is easily searchable and useful as I am working. If it is a consultant note and has a lab or xray in it, my approach is to make a note and say SEE SCAN-so that someone know to go look that there is a document and I say seen by psych/ct brain nl begun on risperdol then my emr puts the lab value( here I mean Xr ) into the lab book and the med into the med lsit. and I can always call up the document by name if Ineed to see itIt is a very good system but it is stupid becasue I have to do work to manage papers and info that should be easier if we all had one emr. Jean Our EMR files it by patient. So I would likely create a file folder for each patient. And then add sub-folders (lab, radiology, consults, hospital, outside records, admin, billing, etc), and title each document by date and what it is (e.g., 4/13/12 chem for a Chem panel done today). Pratt Hello all,Is there some best practice for filing documents. I am fairly inconsistent in my approach to it and would like some guidelines. I want to be able to look at the list of documents and be able to say what it is by looking at its name. so the name would have some indication of patient identity, date, test/report/issue, normal abnormal.So far I havent done a good job of it, mostly because I dont stick to any particular pattern. What do you all do? Sangeetha -- MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 13, 2012 Report Share Posted April 13, 2012 Sangeetha,No perfect system here, but it works: Each patient has folder: . Each folder has sub-folders: ..Clinical Summary others: Demographics, Diagnostic Studies, Labs, Consults, Correspondence, Records (for prior stuff coming in), and Temp (for stuff like PT orders or RX's that have to be printed out and emailed or something; these can be deleted at some point). I use .M.2012.4.12.Lab.TSH high, so it all stays in order and easily scanned, with some notation that is helpful to me. Experimenting with Smart Folders on Apple so the stuff goes where it should without me having to do anything besides naming it. If someone gets tons of something in one folder, I'll make an archive inside the folder, ie .M.Labs.Archive.2007-2010 Sharon Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com Our EMR has a flag for abnormal, so we don't have to put that in the title. But can't you just use " a " for abnormal and " n " for normal? I would come up with a " key " of abbreviations and print it out and put it on my desk to refer to. If it is filed to the patient's chart, why are you putting the patient name on it? If you have to scan and then import it into the chart, I think I would create folders for each patient and scan to that fold before importing....without putting the name in the title of the document. Pratt Thats what I do too.. mur, san, date, therapy shoulder rimprovedOR doe , jan 3/2012 cardiac stress test nml filed into the patients's chart, under, whatever category, but the name now gives me all the info I need at a glance even when I print it out The last part is key, so then I dont have to open the document, to see the conclusion.I was just thinking, surely somebody is doing something better than that? Sangeetha Are we talking about things you scan in? I can link it to the emr but have never done so I just do it by name and date and topic eg Antonucci,psych eval 3-12. or Antonucci, psych eval f/u 412 so that it is easily searchable and useful as I am working. If it is a consultant note and has a lab or xray in it, my approach is to make a note and say SEE SCAN-so that someone know to go look that there is a document and I say seen by psych/ct brain nl begun on risperdol then my emr puts the lab value( here I mean Xr ) into the lab book and the med into the med lsit. and I can always call up the document by name if Ineed to see itIt is a very good system but it is stupid becasue I have to do work to manage papers and info that should be easier if we all had one emr. Jean Our EMR files it by patient. So I would likely create a file folder for each patient. And then add sub-folders (lab, radiology, consults, hospital, outside records, admin, billing, etc), and title each document by date and what it is (e.g., 4/13/12 chem for a Chem panel done today). Pratt Hello all,Is there some best practice for filing documents. I am fairly inconsistent in my approach to it and would like some guidelines. I want to be able to look at the list of documents and be able to say what it is by looking at its name. so the name would have some indication of patient identity, date, test/report/issue, normal abnormal.So far I havent done a good job of it, mostly because I dont stick to any particular pattern. What do you all do? Sangeetha -- MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 13, 2012 Report Share Posted April 13, 2012 Until my EMR gets a robust fax option, when I have to fax records out, I have to download the docs, then upload them. Its nice if I can identify which documents at a glance. Sangeetha Our EMR has a flag for abnormal, so we don't have to put that in the title. But can't you just use " a " for abnormal and " n " for normal? I would come up with a " key " of abbreviations and print it out and put it on my desk to refer to. If it is filed to the patient's chart, why are you putting the patient name on it? If you have to scan and then import it into the chart, I think I would create folders for each patient and scan to that fold before importing....without putting the name in the title of the document. Pratt Thats what I do too.. mur, san, date, therapy shoulder rimprovedOR doe , jan 3/2012 cardiac stress test nml filed into the patients's chart, under, whatever category, but the name now gives me all the info I need at a glance even when I print it out The last part is key, so then I dont have to open the document, to see the conclusion.I was just thinking, surely somebody is doing something better than that? Sangeetha Are we talking about things you scan in? I can link it to the emr but have never done so I just do it by name and date and topic eg Antonucci,psych eval 3-12. or Antonucci, psych eval f/u 412 so that it is easily searchable and useful as I am working. If it is a consultant note and has a lab or xray in it, my approach is to make a note and say SEE SCAN-so that someone know to go look that there is a document and I say seen by psych/ct brain nl begun on risperdol then my emr puts the lab value( here I mean Xr ) into the lab book and the med into the med lsit. and I can always call up the document by name if Ineed to see itIt is a very good system but it is stupid becasue I have to do work to manage papers and info that should be easier if we all had one emr. Jean Our EMR files it by patient. So I would likely create a file folder for each patient. And then add sub-folders (lab, radiology, consults, hospital, outside records, admin, billing, etc), and title each document by date and what it is (e.g., 4/13/12 chem for a Chem panel done today). Pratt Hello all,Is there some best practice for filing documents. I am fairly inconsistent in my approach to it and would like some guidelines. I want to be able to look at the list of documents and be able to say what it is by looking at its name. so the name would have some indication of patient identity, date, test/report/issue, normal abnormal.So far I havent done a good job of it, mostly because I dont stick to any particular pattern. What do you all do? Sangeetha -- MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 14, 2012 Report Share Posted April 14, 2012 Does it present a problem if you are searching by document title and have multiple 's in practice? Ie - do you need to put in a DOB as well? I realize this would be a lot more key strokes. Some EMRs (and Updox I believe?) have an algorithm for naming the document automatically. ie - last name, first name, doc type, date, etc But I wonder how others deal with two patients with same name as far as title of a scanned or imported document? . Mike Safran Quote Link to comment Share on other sites More sharing options...
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