Provider's Guide

Documenting a Patient Encounter

Documenting a patient encounter so your patient's MedKaz always is current sounds far more complicated and time consuming than it is.  It is easy to master and will take little of your assistant's time, far less of yours.

While there will be variations and exceptions, there are only three basic steps to remember:

1. You must complete an Encounter Summary form for each patient encounter; you can do so while your patient is present or save it to your PRM and finish it later even after your patient has gone.
2. Your assistant must scan all paper documents related to each patient encounter and batch them with other digitized documents relating to the same encounter.
3. Your assistant must upload the batched encounter documents to the MedKaz Server, correct and verify them for accuracy after they have been processed by the Server, and download them to both your patient's MedKaz and your PRM.

Start with the Encounter Summary

If you keep paper charts and do not have a computer in your office or exam rooms, your assistant will have printed your patient's Encounter Summary along with the other documents awaiting you, and will have put them in your patient's chart.

The Encounter Summary will be partially pre-populated.  You must complete it with information from your patient examination: 

1. The Reason/Chief Complaint section will be pre-populated if your patient completed the Pre-Visit Questionnaire.  If it is blank, hand-print their complaint(s).
2. Hand-print your patient's vitals (the MedKaz Server computes the BMI for you) and your assessment of their condition (hand-print the rest of your progress notes on the Encounter Summary form, or write them on a separate sheet of paper).
3. Check-mark any new chronic diseases, allergies, or medications you ordered; put checkmarks next to medications you instructed your patient to stop taking; print the names of immunization shots you gave your patient.
4. Most importantly, put checkmarks on the Body Systems and dark dots or circles on the anatomical drawing to indicate the Body Systems and Body Locations that were the subject of the visit.
5. Put all documents relating to the encounter, the Referral Request, Pre-Visit Questionnaire Report, Health Summary, completed Encounter Summary and any other documents in your patient's chart and give it to your assistant.
6. If you do not complete everything while your patient is still there, you or your assistant should hold the chart until all documents are completed and ready to be processed.
7. The remaining steps are completed by your assistant.
8. If your patient arrives without their MedKaz, your assistant should log on to the MedKaz Server to download a blank Encounter Summary form, print it out and place it in your patient's chart.  You complete it as you would one generated by your patient's MedKaz.  Your assistant then can process it along with any other documents relating to the encounter and then download them to your patient's MedKaz and your PRM.

If you keep paper charts and have a computer in your office or exam rooms, plug your patient's MedKaz into your computer, log on and ask your patient to enter his or her password.  The MedKaz opens to a Document Viewer containing documents waiting for you: a Referral Request (if your patient was referred to you by another care provider), a Pre-Visit Questionnaire Report (if your patient completed one in advance), a fully-populated Health Summary and a partially-populated Encounter Summary.

Using your computer, complete the Encounter Summary.  Enter the following information: 

1. The Reason/Chief Complaint section will be pre-populated if your patient completed the Pre-Visit Questionnaire.  If it is blank, key in their complaint(s).
2. Key in your patient's vitals (the MedKaz Server computes the BMI for you) and your assessment of their condition (you may enter the rest of your progress notes on the Encounter Summary form or write them on a separate piece of paper).
3. Check-mark any new chronic diseases you have identified; key in the names of new allergies you identified or medications you ordered; enter checkmarks next to medications you instructed your patient to stop taking; enter the names of immunization shots you have given.
4. Most importantly, using your cursor, check the boxes indicating the Body Systems and put dots on the anatomical drawing to indicate the Body Systems and Body Locations that were the subject of the visit.
5. Save all completed documents relating to the encounter in the Encounter Folder on your patient's MedKaz by closing the Document Viewer; they should include: a Referral Request and/or Pre-Visit Questionnaire Report (if they were on your patient's MedKaz), the Health Summary, and the completed Encounter Summary. Give any other documents related to the encounter to your assistant.
6. If you cannot complete everything while your patient is still there, click Finish Later on the Document Viewer and the documents will be saved to your PRM for you to finish later. When you open your PRM it will list any Encounter Folders awaiting completion; when you finish them, click Done to save them to your computer - for your assistant to upload, correct and verify.
7. The remaining steps are completed by your assistant.
8. If your patient arrives without their MedKaz, you should access your PRM, enter the patient's name, click once to select them, and then select Encounter Summary from the Forms menu.  You key-in the data as you would do if your patient had brought their MedKaz.  You also can log-on to the MedKaz Server to download and print out a blank Encounter Summary form. You write in the data and insert the completed form in your patient's chart. Your assistant then can process either form along with any other documents relating to the encounter and then download them to your patient's MedKaz and your PRM.

If you have an EMR system, before examining your patient you definitely should read the documents waiting in the Document Viewer on your patient's MedKaz even though you have your own EMR system. If you don't, you will have to waste time trying to extract this same information from them.  You may need to save the Referral Request for submission to your patient's insurance provider, and you definitely will want to see the Pre-Visit Questionnaire Report and Health Summary so you are fully up-to-date with their situation.

1. To access this information, plug your patient's MedKaz into your computer, log on, and ask your patient to enter their password.  These documents will open in the Document Viewer.  When you have read them, save them in the Encounter Folder of your patient's MedKaz by closing the Document Viewer for your assistant to process later along with a copy of your EMR-generated progress notes.
2. When finished treating your patient, complete and save your progress notes in your EMR system. Then, generate and save on your computer two documents your assistant will process and upload to the MedKaz Server for subsequent downloading to your patient’s MedKaz and your PRM (if you use one).
   
   One document is a copy of your progress notes which, depending upon your system, you may generate in a standard XML format or as a PDF document. The other is a copy of the report your system generates that summarizes your patient’s condition. It may be called a CCD, HITSP/C32 or another name and can usually be generated as a PDF document.
   
   Save copies of both your progress notes and the summary document to the Encounter Folder on your computer containing any other encounter-related reports. Your assistant can upload these files directly to the MedKaz Server without having to scan them.
3. If your patient arrives without their MedKaz, you should open your PRM, enter the patient's name in the Search field, click once to select him or her, and then select Encounter Summary from the Forms menu, and it opens in the Document Viewer. You key-in the data as you would do if your patient had brought their MedKaz.  You also can log on to the MedKaz Server to download and print out a blank Encounter Summary form. In this case, you write in the data and give it to your assistant. Your assistant then can process it along with any other documents relating to the encounter and then download them to your patient's MedKaz and your PRM.

When you have completed your patient’s Encounter Summary, you must sign it.  To sign it electronically, click the Sign button and enter your password when prompted. 

When you correctly enter your password, the document shows that it has been digitally signed:

Radiology Summary

The Radiology Summary is a working document used by both the requesting provider and the radiologist.  As a requesting provider, you fill in part of the form, requesting the study you want performed; the radiologist completes it when they report their findings and impressions.

The radiologist sends it to you with or without the underlying images.  Your assistant scans it and uploads it to the MedKaz Server – with images if they are available; verifies it; and sends it to the MedKaz Server which, in turn, sends your patient and you an e-mail message to download it.

To create a Radiology Summary:

1. Click Radiology Summary on the Forms menu.
2. Fill out the report either on your computer or by hand, indicating the radiologist or institution that will perform the study, and the study you want performed
3. Click Done to save it on the MedKaz. You can also print it and either give it to your patient to deliver to the radiologist, or send it to the radiologist directly. 

When the technician or radiologist logs on to your patient’s MedKaz, it will be displayed in the Document Viewer and they can save it to their computer or print it out.

The radiologist reads the images and enters their Findings and Impressions either on the Radiology Summary or their own form which they can attach to the Radiology Summary. They also check boxes indicating the Study and Document types and Body Systems covered by the study, as well as put dots on the anatomical drawing to indicate Body Locations.

When you receive the completed report from the radiologist:

1. Your assistant scans it for use as a 'batch header' for radiological images.
2. You select the images or image slices that best illustrate your patient's problem.
3. Your assistant uploads the Radiology Summary and related images to the MedKaz Server to be processed, just as they do with an Encounter Summary.
4. Your assistant verifies the results.

If the report you receive is not on a MedKaz Radiology Summary form, the process is exactly the same.

Processing Overview

Your assistant or another staff person presumably will process the records you created during your patient encounter and saved to an Encounter Folder for subsequent loading onto your patient's MedKaz and your PRM. The following information provides an overview of this important activity; it is addressed to your assistant. 

1. There is no limit to the number of record pages that can be uploaded as part of an encounter, but only one Encounter Summary can be included for each encounter. It is a key document in the MedKaz system because it contains information used to index and organize all the records relating to the encounter.
2. When you get a patient's MedKaz after an encounter, make sure you understand the state of the documentation.
   • Completed and saved on the MedKaz  You must open the MedKaz (both you and the patient must log on to do so), examine the contents of the Encounter Folder and ensure the documents are complete, and click Done. If they are not complete, you can complete some items - filling in vital signs, for example. Other items may require the care provider to complete.
   • Incomplete and saved in the PRM for subsequent editing  The care provider will need to log on to the PRM and complete the encounter documentation, then click Done to save it as a PDF. 
   • Completed and saved as PDF files  The documents were created by computer and already are digital so all you need do is upload them to the Server for processing.
   • The care provider filled out the Encounter Summary form by hand  You must ensure the form is complete and then scan it.
3. When the Encounter Summary is complete click Done to save it in the patient's Encounter Folder on your computer as a PDF document. Scan other documents as TIFFs. Once all documents have been scanned, move the scanned images to the same Encounter Folder. These PDFs and TIFFs can be printed out and saved in a paper chart, but must be converted into text documents before they can be read and searched electronically by a computer. The MedKaz Server performs this conversion. Encounter files can be uploaded to the Server in any order, but it's recommended that you upload the Encounter Summary first.
4. Applications on the Server use sophisticated pattern matching to "read" each character on a PDF or TIFF document and determine what letter or number it is. The Server does this both for documents that have been filled out on the computer and for those that have been filled out by hand.
   
   Other documents in the same Encounter Folder previously scanned and saved as multi-page TIFF files - such as progress notes available while the patient is still there - are uploaded to the MedKaz Server as a batch with the Encounter Summary, where they are "read" and turned into computer-readable text - so care providers can sort, search and read them electronically on the MedKaz and PRM. If your provider dictates their notes, uploading the Encounter Folder may be delayed a day or two until the transcribed progress notes are available. However, do not delay the upload if your patient is likely to seek care from other providers within days. In this situation, upload the completed records immediately, and delayed notes as soon as they are available.
   
   Documents relating to the encounter that are delayed for days, such as test, or lab reports, or Radiology Summaries, should be uploaded when you receive them.
5. Computer reading and interpreting of characters and numbers is not perfect, and therefore it is imperative that you compare the original scanned file with the interpreted text version to ensure it has been accurately translated. In the verification process, the original document and interpreted text are displayed side by side so they can be compared and corrected if necessary.

Scanning Documents

For paper documents to be uploaded to a patient's MedKaz and your PRM, they must be scanned and saved to a file that subsequently is added to the Encounter Folder and uploaded to the MedKaz Server for processing and indexing. Examples of these types of documents may include:

• Transcribed progress notes
• MedKaz forms that have been filled out by hand
• Reports from referral providers
• EKG scans and other test results

When you scan a document, be sure that the name of the scanned image file includes the date and the patient's name. Add them to the appropriate Encounter Folder that is uploaded to the MedKaz Server.

To maximize the quality of the scan, set your scanner settings as follows:

• Type of document: TIFF or PDF
• Resolution: 300 dpi (dots per inch)
• Output: Grayscale
• Number of pages in file: Multi-page files (documents with two or more pages are saved in a single file)

Make sure you know the default directory where the scanner saves files; you must know the location of scanned files when uploading records.

Uploading and Verifying Documents

When all documents relating to a particular encounter have been assembled in an Encounter Folder on your computer, they are ready to be uploaded to the MedKaz Server. Once uploaded, they are processed in real-time.  Actual processing and indexing takes less than a minute for small files, more for larger ones.

1. Log on to the MedKaz portal at http://medkaz.com/logon, click on Upload Scanned Documents, and select Upload Documents.  The upload screen opens by default to upload an Encounter Summary.  If you are uploading a different type of document, select the appropriate document, such as a Lab/Test or Radiology Summary, from the Type of Document drop-down; the appropriate upload form will be displayed.  In any case, it will be partially pre-populated with information.
2. Complete the Upload form, attach the relevant documents relating to the Encounter (or Test or Radiology Summary) and upload them as a batch to the Server where they automatically are logged in for processing, and listed in the Status Report as Uploads in Process.  Click here for detailed instructions for uploading documents to the Server.
3. When the Server has processed and indexed them, the Status Report lists them as Uploads to be Verified.
4. On the Status Report screen, click on the document to be verified.  A Verification screen opens displaying the original side-by-side with the processed data. As you tab from field to field to verify or correct the data, the active field is highlighted on the original image so you can easily compare the two. Click here for detailed instructions for verifying documents on the Server.
5. You repeat this process for each document.  When finished, if the patient is present, the encounter records are downloaded to the patient's MedKaz and the provider's PRM. If not, the Server sends both the patient and provider an e-mail that it has records for them.  When the patient and provider Sync to the Server, the records are downloaded to the patient's MedKaz and provider's PRM, and erased from the Server.