Document Scribing
- Assisting the provider in navigating the EHR
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- Responding to various messages as directed by the provider
- Locating information for review (i.e., previous notes, reports, test results, and laboratory results)
- Entering information into the EHR as directed by the provider
- Researching information requested by the provider
Service Details
We will provide the following services as described.
Extract content from EMR
Content to be extracted includes the following
- Active clinical data for Problems, Medications, and Allergies
- Clinical notes for the past 1 year
- Lab reports for the past 1 year
Clinical data will be extracted using the following rules
- Problems – the active problems list, including ICD9 code and description will be exported into a document.
- Medications – the active medication list, including drug name, strength, form, sig, and start date will be exported into a document.
- Allergies – the active allergy list, including allergen and reactions will be exported into a document.
Clinical notes will be extracted using the following rules
- The office note will be exported to a PDF or Text file.
Lab report documents will be exported using the following rules
- One document will be exported per report
Enter patient demographics into EMR
- Includes name, gender, date of birth, contact (address, phone), and email
- If email is unknown, a formula will be used to create the address
- Information not carried over include: chart ID, insurance policies, emergency contact, next of kin, employer, race, ethnicity
Enter clinical content into EMR
Clinical data will be entered using the following rules
- Problems – using the ICD9 code provided, the associated problem will be added. Only ACTIVE problems will be entered. Date of onset will not be carried over.
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Medications – using the medication name, strength, and form, the associated medication will be added. If a match is not found, the medication name, strength, form, will be keyed manually. The SIG will also be entered.
Only ACTIVE medications will be entered. The prescription details, such as quantity, # of remaining refills, pharmacy will not be carried over.
Medications the patient is no longer on will not be carried over.
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Allergies – the allergen (drug, food, environmental) will be entered, along with any known reactions.
Only ACTIVE allergies will be entered. Date of onset will not be carried over.
Clinical notes will be entered using the following rules
- An Office Visit will be created for each note, with Chief Complaints set to “OV mm/dd/yy” (where date is the Date of Service)
- The text of the clinical note will be copied into the text area
Lab report documents will be imported using the following rules