Document types definition

 

Clinical Documents are displayed in a view that is customizable by each user with the Configure Layout link. To set up the view for the most efficient use, these are the definitions of the document types to be found under each heading. Drag the document type to the window where you want to see that data. More than one type can be in a single window- there will be tabs to view each type.

Results - This tab displays all results with the newest on top do not remove this tab from your view unless you have radiology, laboratory and all Encounter and Document views available and you do not want to see all the documents in a composite view. The documents in Results will also be found under their specific document type in the display. Allergies - This tab will display patient medication allergies populated by facility registration messages. Currently we are receiving no allergy information. Documents – These are messages which are created within the HIE or added to the HIE by Continuity of Care messages from Electronic health records. (CCD) Care Management- Care management documents are not currently available in our community Ambulatory Encounters – Encounter demographic information only. No textual data. Inpatient Encounters- Hospital documentation of patient visits Emergency Encounters – Documentation of Emergency Room visits. Complete documentation from Dominican Hospital ER. Only ordered lab and radiology reports from Watsonville Hospital. No physician notes. Functional Status - Personal self-maintenance assessments (PSMS) and Activities of Daily Living (ADL) assessment. This information will be available soon from care documents which are not currently being populated in the HIE. Immunizations – Immunization data will be present from providers who use Electronic Health Records and who record immunizations in their database. Medications – Medications captured in hospital admit records and from Electronic Health Records and some historical medications are available in the HIE. More will be available as records in CDA format are created and exchanged. Problems – Problems are present if captured in an electronic health records or hospital admit. More will be available as patients populate the SCHIE patient portal. Procedures – Procedures are present if captured and transmitted by electronic health records. More will be available as patients populate the Santa Cruz Health Information Exchange patient portal. Social History - Social history will be populated from the patient portal and other electronic health records sending this information in standard clinical document format. Vitals – Vitals are populated from hospital admit and Electronic health records

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Laboratories – Historical and current laboratory results, including but not limited to: Quest, LabCorp, Dominican Hospital, Watsonville Hospital and Dianon. Imaging – Radiology reports, including but not limited to: Radiology Medical Group of Santa Cruz County Inc., Santa Cruz Comprehensive Imaging, Dominican MRI Center, South County Imaging, Dominican Breast Center, Dominican Radiology and Watsonville Radiology Documentation- Documents from transcription, encounters from Electronic health records also called chart notes or memos, surgical history & physical (H&P), authorizations, encounters created on form templates. Other Orders – Not currently used.

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