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Viewing New Clinical Documents

This section provides instructions for accessing all new clinical documents such as electronic and uploaded radiology results, diagnostics, clinical notes, and other documents that are received into Care360 EHR, regardless of the patient for which the documents were received. The New Clinical Documents area displays all non-lab clinical documents that have recently been received into Care360 EHR for your particular organization or care site. This allows you to quickly view or print the latest documents, and when applicable, forward a document on to a patient. In addition, you can also assign diagnostic descriptions to clinical documents that are categorized as diagnostics or radiology.

All clinical documents received by Care360 EHR (regardless of whether or not they are “new”) are saved to the associated patient’s summary. So, even though a document may no longer appear on the New Clinical Documents list, it is always available by accessing that patient’s summary. (For instructions on accessing a patient summary, see Accessing a Patient Summary.) Access the following patient summary sections to view specific documents:

• Radiology Results. The Radiology Results section of the patient summary provides access to any radiology results (textual, transcribed, or uploaded) that have been received for a particular patient. For more information on viewing patient radiology results, see View a Patient’s Radiology Results.

• Diagnostics. The Diagnostics section of the patient summary can include textual, transcribed, or uploaded diagnostics results for a patient. For more information on viewing patient diagnostics results, see View a Patient’s Diagnostic Results.

• Clinical Notes. The Clinical Notes section of the patient summary displays a list of uploaded documents (consults, referrals, discharge summaries, encounter notes, progress notes, and History and Physical Examinations [H&Ps]), electronic documents (procedures, consults, referrals, discharge summaries, progress notes, and H&Ps), and finalized encounter notes for a patient. For more information on viewing patient clinical notes, see Viewing Clinical Notes and Finalized Encounter Notes.

• Other Documents. The Other Documents section of the patient summary displays a list of uploaded documents for the patient which are not categorized as being laboratory, radiology, or notes related documents. Textual documents that are electronically received with no document type specified, will display in the Diagnostics section of the patient’s summary. Transcribed documents that are received with no document type specified will display in the Other Documents section of the patient’s summary. For more information about viewing and uploading documents, see Document Upload.

Note: Uploaded clinical documents are identified by . Selecting an uploaded document opens the result in the program in which it was created.

How Long Are New Clinical Documents Displayed?

Documents remain on the New Clinical Documents list until one of the following occurs:

• The document is manually removed in the list. You can remove one or more, or all clinical documents in the New Clinical Documents list at any time by selecting the document(s) and then clicking Remove Selected. For information on manually removing a document in the New Clinical Documents list, see Remove Documents in the Clinical Documents List.

Note: Removing a document in the New Clinical Documents list does not delete the document from Care360 EHR; it only removes it in this list. All documents (whether new or previously viewed) are always available from the associated patient’s summary.

• The clinical document is viewed or printed. Depending on how Care360 EHR is configured for your organization, the act of viewing or printing a new clinical document, by you or another member of your organization, may remove the document in the New Clinical Documents list.

For more information on printing a clinical document, see Print New Clinical Documents.

When you navigate to another area of Care360 EHR and then return to the New Clinical Documents list, all documents that have since been viewed or printed are removed in the list.

Notes:

• Uploaded documents are not removed in the New Clinical Documents list when they are printed.

• For more information on how documents are removed in the New Clinical Documents list for your organization, see Set Result Preferences for an Organization.

• The clinical document is older than 14 days. If a new clinical document has not been viewed, printed, or manually removed for 14 days after receipt in Care360 EHR, it is automatically removed in the New Clinical Documents list.

The default expiration value is 14 days, but this value can be reduced (as needed) to best fit your organization’s needs (the maximum value is 14 days). For more information about modifying the clinical documents expiration for your organization, see Set Result Preferences for an Organization.

Understanding the New Clinical Documents List

The New Clinical Documents list consists of a table of recently received clinical documents. By default, all new documents are initially displayed in descending order by the report date (newest to oldest).

Note: You can change the default view of the New Clinical Documents list using the general preferences page. For more information on setting general preferences for the lab results and clinical documents lists, see Set User Preferences.

While viewing the New Clinical Documents list, you can re‑sort the data, as needed, by clicking any of the column headings. For example, if you are looking for a document that arrived on a particular day, you can sort the list of documents by clicking the Report Date column heading, and then page to the documents associated with that date. (Clicking a column heading a second time reverses the sort.)

The following is a list of the data columns that appear in the New Clinical Documents list:

• Document. Displays the document description for an uploaded document. Displays a description of the service or a unique document ID (for example, an order number or accession number) for an electronic document.

• Document Type. Displays the document type, such as EKG, Consultation, Cytopathology and more (about 88 different document types are available).

• Diagnostic Description. Displays the document procedure type. The procedure type will be a coded description.

Note: The diagnostic description is solely used for clinical quality measures reporting. For more information on these reports, see Meaningful Use CQM Reports.

• Category. Displays the clinical document category, such as Consult/Referral, Discharge Summary, Electrocardiac, and more (about 19 different categories available).

• Date of Service. Displays the date on which medical services were provided.

• Patient Name. Displays the name (last, first, middle initial) of the patient for whom the clinical document was received or assigned.

• Ordering Provider. Displays the name of the healthcare provider who ordered the test or procedure.

• Report Date. Displays the date the clinical document was received.

• Sending Facility. Displays the identification code of the facility that sent the clinical document. This column will not contain any information for uploaded documents.

• Send to Patient. Displays a link (Send or Resend) that you can click to automatically send the clinical document to the patient’s MyQuest account.

Note: You can only send/resend clinical documents to patients who have a MyQuest account and an established Patient Portal link. For more information, see Patient Portal Accounts.

View New Clinical Documents

Send a New Clinical Document to a Patient

Remove Documents in the Clinical Documents List

Add a Diagnostics Description to a Diagnostics or Radiology Document

View or Edit a Diagnostic Description on a Diagnostics or Radiology Document

Print New Clinical Documents