Medical Record Management Screen

The Medical Records Management screen was built to be a place for your medical records staff to review each record after a patient visit, confirm that all the information was entered accurately and correctly by the student, was verified by their supervising clinician, and that the order associated with the bill had all the correct information.

This screen also allows you to send out a notice to the attending clinician that there are portions of the record which are not complete, to exempt requirements if it turns out they can be safely omitted, and to print the digital documents out for placement into the physical record.

How do I access the Medical Record Management screen?

Medical Record Management is found under the Navigation menu, in the section labeled Medical Record Screens.

You must have a privilege of the same name, Medical record Management, to access this screen.  The privilege is independent of all other privileges, but we recommend that users in your medical records department also have access to the Patient Record and Order Management Screen to review those portions of each episode as well.  

How do I search for deficient episodes?

The top section of Medical Record Management is a search screen.  This allows you to filter episodes by status, dates, unit, and other search criteria.  You can search by client or patients to find specific episodes.  You can also search by the personnel on each episode to find any episodes that were seen by specific students or clinicians.  

Episodes are not considered "deficient" in VetView until they are discharged, so a good place to start searching is Status: Discharged, Option Options:  Deficient, and narrow it down by unit from there.

How do I review the episode, the documents, or the client's bill?

After you have searched for episodes, they will appear in the Medical Record Management screen as a list.

Click on the View button (binocular icon) to open the Medical Record Overview for the episode.

There are two ways to view the components of the episode.  You can CTRL+Click the links to View Episode Bill to see the bill on the Order Management screen, or the Episode Number to jump directly to the episode on the patient record. 

You can also select the portions of the record and click on Print Selected Components to open up a PDF view of the whole episode, but this method only works when the deficient items are present on the patient record, and not missing entirely.

How do I exempt part of the record if it won't be required?

If the circumstances for the missing document or document verification excuse its absence (such as a surgery report missing when a surgery was cancelled, for example), you can manually exempt the record.

Click on the Medical Record Category that you want to exempt, and click on Edit Requirement.  

A special window will pop up that lets you modify the level of requirement that was built into the Episode Type.  (Requirement levels can also change when a document is added that has a verification requirement.  That will force the Medical Record Category to which it belongs to now also require to be verified.)

To change the requirement levels, uncheck the boxes and click on Save.  To exempt it, click on the Exempt button. 

The user who provided the exemption as well as the date and time will automatically be recorded, and display on the main screen. 

The comments will be stored and displayed for non-exemption changes, such as removing a verification requirement. 

When all parts of the medical record are Sufficient or Exempt, the status of the entire record will change to no longer being deficient without any additional steps needed.

How do I inform the supervising clinician that parts of the record are incomplete?

There are two ways to sent an internal VetView notice to a clinician whose episodes are deficient.

From the search screen, search by the parameters you need to filter it down to a specific DVM, unit, date range, etc.

Click on the box on the column header to select all episodes that match the criteria selected.

Then click on the Notify Clinicians button to send them a single email with a list of episodes they need to review.

Within the Medical Record Management screen, you can send a more detailed notice to multiple users.

For example, if a student failed to fill out the document, you can tag both the student and the supervisor to have the document reviewed by both users.

Click on the Deficiency Note button to load this screen.

This will load a window where you can leave a custom message for relevant people describing exactly what the issue is. 

How do I print out the whole record at once, or only the missing parts?

To print the entire Episode of Care, click on the check box next to Record Group.  This will select all the parts of the medical record.

Then click on the button that says Print Selected Components.  For all parts of the medical record that can be printed, a single PDF will load.  This can then be printed all at once.

You can also print only part of the medical record, if some of it was previously printed, or the documents are not relevent to the episode.

Click on the check box next to the section you want to print, and then click on Print Selected Components.  A PDF of only documents in that category will load.

How do I close the episode once everything is done?

When the episode has been fully reviewed and confirmed to be completed, you can change it from Discharged status to Closed on this screen by clicking the Close Episode button.