How to sign my transcriptions
The Santa Cruz Health Information Exchange is integrated with nSight transcription supported by Axesson. A provider can use a digital voice recorder (DVR) or their iphone to dictate an encounter, letter, memo etc. which is uploaded to the nSight transcription company and returned within 24 hours directly into the SCHIE. The dictating provider, and only the dictating provider, will be able to edit, save and sign their transcribed documents. The signed document will automatically flow to a provider with an interfaced Electronic Health Information Record. The provider or staff can also use the functions of the HIE to Share the document with any other provider. (See How Do I Share a Result) To Sign Transcription ( Please see the How Do I set IE for Document Signing if you are using Internet Explorer to access the website.)
1. Locate the Patient – Go to the patient tab, use the Search to find the patient.
2. Click on the patient to open the patient’s clinical documents.
3. Make sure that you have the Documentation document type selected to appear on your results view. There is also a results type called Documents - this is not the correct view.
4. Your transcribed dictations will appear in the window with the Date of delivery of the document ( not the date of dictation – that will show on the document itself) The name of the document –the source , nSIGHT Transcription,-and a column headed Sign/Edit. Unsigned transcription will have the word DRAFT in front of the document and a RED PEN in the Sign\Edit column.
5. Transcriptions that have been Edited and Saved, but not signed will also appear in this view with the word EDIT appended to the document name and will have the RED PEN. Signed transcriptions will show the name of the document only eg. Progress Note
6. Click on the RED PEN to open the document. You can now Edit the document.
7. The open document has three buttons at the bottom.
8. Cancel – does not save your edits Save – saves your edits but leaves the document in a non-signed format. The document name changes to EDIT and a notation stating the editing provider is shown on the document. Sign – Signs the document, locks it and sends it downstream to other providers EHRs if applicable A document can be Saved and Edited any number of times. Once a document is Signed it is locked and cannot be changed.
9. After any of these buttons are used – a legend requesting the user to Refresh appears at the top of the page. The Refresh button must be clicked to show the edited or signed document in the patient results.
10. Signed transcribed documents will be delivered to the “cc” providers per provider preference and will be available from the patient results in the HIE.