Electronic Medical Record Scanning Procedures
Files available for scanning in records:

OP Reports and Pictures: All DISD physician Op Reports and pictures
from surgery are scanned in this file. It appears in the chart in BLACK
print and does not need to go to the Physician/Assistant work list.

PA Dictation: Transcription files the Physician Assistants dictation into
this file. It appears in BLACK print and requires the supervising
physician to sign off, so it does need to go the Physician/Assistant work
list.

IME from non-DISD provider: All outside IME’s are to be scanned in
this file. It appears in BLACK print and needs to go to the
Physician/Assistant work list.

Transcription: Transcription electronically saves the dictation into this
file. These appear in BLACK ink and needs to be signed off by the
dictating physician. NP packets are to be scanned under this file.

Diagnostic Reports: ALL Diagnostic reports i.e. MRI, outside x-ray, CT
Scans, Bone Scans, Labs, Pre-op Clearances, are to be scanned in this file.
These reports appear in BLACK print and need to go to the
Physician/Assistant work list to be signed off by the ordering physician.

SX Scheduling Forms: SX forms requesting authorization. These appear
in HOT PINK print and do not need to go to the Physician/Assistant work
list.

Insurance/Registration Forms: Copy of insurance card and registration
forms go in this file. It appears in RED print and does not need to go to
the Physician/Assistant work list.

Authorizations/Referrals/Eligibility: This file needs to include
authorizations for diagnostic tests, PCP referrals, and Eligibility reports.
They appear in HOT PINK print and do not need to go to the
Physician/Assistant work list.

Billing Letters/Financial Agreements: This file is for the billing
department. Anything scanned in this file will appear in GREEN print and
do not need to go to the Physician/Assistant work list.
1

Case Manager/Adjuster Requests: Anything from a nurse case manager or
adjuster that requires the response of either the physician or the assistant.
This will appear in MAROON print and needs to go to the
Physician/Assistant work list.

Consultations: All hospital consultations done by a DISD physician need
to be scanned in this file. The document will appear in BLACK print and
does not need to go to the Physician/Assistant work list.

Correspondence: All written documents from the patient to DISD,
including email traffic between DISD staff and the patient. These will
appear in GREY print and need to go to the Physician/Assistant work list.

Disability Forms: All Disability forms, handicap placards, FMLA forms for
the spouse or the family member of the patient. These will appear in
BLUE print and do not need to go the Physician/Assistant work list.

Legal: This file is for the Medical Legal Coordinator. These documents
will appear in PURPLE print and do not need to go to the
Physician/Assistant work list.

Medical Records Release Forms: All Medical Records Release forms,
whether a DISD form or an outside form. They will appear in PURPLE
print and do not need to go to the work list.

Outside Records: All records from a non DISD physician. This includes
records collected for NP’s. These records will appear in BLACK print and
do not need to go to the Physician/Assistant work list.

Physical Therapy Notes: Outside P.T. notes. They will appear in OLIVE
print and do not need to go to the Physician/Assistant work list.

DISD P.T. Plan of Care: DISD P.T. notes. They will appear in OLIVE
print and do not need to go to the Physician/Assistant work list.
Please Note: Use only the folders listed above, we are in the
process of eliminating folders that are not needed in this practice.
What do the colors represent?
The documents that are printed in black let the physician know that those
documents are directly related to patient care such as DISD physician notes, non
DISD physician notes, diagnostic reports, lab results, etc. This helps save time
during clinic by not having the physician going through everything in the chart
when all he/she needs is a report.
2
Most of our patients develop large charts over time and color coding the various
documents that are required by law to be kept in patient charts helps everyone
with visual cues to locate items needed.
How to “Name” the documents that we scan?
Each document scanned into MDPlus must have the following information
included when filling in the description;
1. The date of service on the document, or the date of the document if not a
medical document.
2. The FULL name of the document, for example MRI LSpine, CT Scan
CSpine, EMG LUE (left upper extremity) NOT MRI, CT, EMG, etc. It is
important that the physician know what the document is BEFORE he
opens it. Not to mention most patients end up having more than 1 MRI
during treatment, so it is important to have the date of service visible in
the chart. There are only 2 exceptions to this rule, one is NP outside
records, and they can be scanned in together. Although we need to label
these records as “NP outside records” not APPT request. The second
exception is “Pre-op Clearances”, these can also be scanned in as 1
document as long as they are received together. Sometimes patients
require additional clearances by other specialists, so those would be
scanned in as separate documents as “081606 Surgical Clearance Dr. Soand-so Pit/LDS”.
3. The treating DISD Physician’s last 3 digits of their name must appear after
the description. For example, PIT, HES, or SON. As we continue to
expand we need to begin labeling the provider since our patients will be
seeing more than one DISD physician.
4. Lastly, you must put your initials after the physician initials so that there is
accountability with everyone scanning.
Some Examples:
20070816 MRI LSpine Pit/LDS
20070822 EMG LUE Pit/LDS
20070812 Pre op Tests Pit/LDS
20070815 Cardiology Surgical Clearance Dr. Smith
Pit/LDS
20060816 OS (outside) P.T. Progress Note Pit/LDS
*** OS indicates that the service is not from DISD
20060816 P.T. POC (plan of care) HES/LDS
Important Reminders
 Before shredding your document, make sure that the copy you scanned
is legible in the electronic chart. This includes insurance cards!! If you
3









receive a poor quality fax that needs to be scanned, call the facility and
ask them to re-fax the document and if it continues to be a problem,
tell the sender to mail us a clear copy. Anything and everything we put
into a patient’s EMR becomes a legal document that can be ordered by
a subpoena and there are legal liabilities if we present records that are
poor quality and not legible.
Abbreviations: These are standardized in medicine and we can not use
our own made up abbreviations. If you do not know what is accepted
by the AMA (American Medical Association), write things out. If you
are interested in the most updated approved abbreviation list, let me
know and I would be more than happy to provide you with one. Again,
this is a legal issue and we must abide by the regulations set for us at all
times.
All Diagnostic Reports that arrive either via fax or mail can go directly
to the scan box. These items go to the work list and it is not necessary
that they get viewed twice. The one thing to keep in mind is if we get
behind in scanning, we need to prioritize our scanning and all reports,
test results and outside consults need to be scanned within 24-48
hours from the time of arrival.
When scanning records that were reviewed put them under “outside
records” and label them NP outside records and put the Appt
Request as the last page. This will help the doctor during clinic.
CONSISTANCY and PRIDE IN ONE’S WORK!!! (Speaks for itself)
ALWAYS look and make sure that you are not rescanning a document
that is already in the EMR. We often get the same document several
times, it is really frustrating for the physician to see the same document
more than once when it appears on the work list, plus it is extra work
for staff. Please, Please, Please be aware of what you are scanning.
It is the responsibility of the entire staff to take responsibility in
ensuring that all of our charts are maintained not only with integrity
but that we follow all guidelines that are established by DISD and
outside entities, i.e. HIPPA, State and Federal Laws.
Since there are several different items that can go under the same
“folder” please label documents what they are. For example, in the
past I have seen things under Insurance / Registration that were
generically labeled, example Aetna or HIPPA. Be more specific, Aetna
Ins. Card or Eligibility Report depending on what it is. Instead of
HIPPA, say “Notice of Privacy Practices”, or even “signed HIPPA
form”. Bottom line… it should be clear as to what the document is
before it is opened.
MAKE SURE YOU ARE SCANNING DOCUMENTS IN THE RIGHT
CHART!!! I received a subpoena on a chart and while preparing the
documents that needed to be sent to the judge, I noticed 2 reports that
did not belong to that particular patient.
If documents that are scanned in by you are found to be poor quality,
unreadable, labeled incorrectly, in the chart multiple times, etc., be
prepared to be given the task of making the necessary corrections.
4