When scanning documents, do the following:
1. Save documents with the patient’s name (last name, first name).
2. Add additional information for each document as follows:
•X-rays/ultrasound/medical imaging – If there is a summary, comment, or impression, include this information. If this information does not exist, you must type in the report text.
Note Sometimes two or more areas are reported on one x-ray report. It is important that staff record both and bold each area, so the physicians can see both easily.
•Consult from a physician – Add the physicians name.
•Reports or records faxed to a lawyer or insurance company – Add the date received, who the request was from, and what date it was faxed or mailed. The message can be archived right away as the physicians have seen it.
•ECG Reports – Add whether the report is Normal or Abnormal and any comments.
•Walk In Clinic Reports – Add the physician’s name if legible or the name of the clinic and the reason for visit.