/depts/,/depts/uwhealth/,/depts/uwhealth/him/,/depts/uwhealth/him/enterprise-content-management/,

/depts/uwhealth/him/enterprise-content-management/

20170253

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100

UWHC,UWMF,

Health Link,Medical Records,

Departments & Programs,UW Health,Health Information Management

Enterprise Content Management

Enterprise Content Management - Departments & Programs, UW Health, Health Information Management

Focus

Health Information Management (HIM) is responsible for maintaining a complete and accurate medical record that meets State and Federal regulations as well as accreditation standards. To accomplish this, all paper and electronic documentation tools/forms that are included in the UW Health medical record must follow a process for approval. Before the tools/forms can be included in the record, they must be approved by the HIM-Enterprise Content Management (ECM) Team (unapproved forms may not be included in the medical record). Once the electronic or paper documents are approved they will be declared as the legal source. Paper documents are scanned into the Electronic Medical Record (EMR), while approved electronic documents are either directly entered into the EMR or interfaced via ancillary Systems.

Any print groups or system level build see Health Link Content Management and Style Guide for more direction.

NOTE: To ensure that the most current version of a medical record form is used, the Medical Records Forms Library is the source of access.

FAQ

As paper forms convert to electronic documentation in Health Link, is there anyone that should be notified that the paper form is no longer used?

Yes, please let HIM-Enterprise Content Management (ECM) know by submitting a ServiceNow ticket. Provide the form title of the form and the form number (bottom left corner of the form). ECM will work on deactivating the form once the ServiceNow ticket is received.

Can content be created within Health Link that contains a manual signature for either the clinician or patient to sign?

Health Link is only able to collect a manual signature electronically for registration at this moment. This project is continually being work on. Any other documentation that requires a manual signature needs to remain on paper.

Can I request a Consent Form to be created in Health Link and have a patient sign it electronically during a visit?

Consent to treatment and HIPPA acknowledgement forms are available by electronic signature for Registration. Other consents still remain on paper until functionality becomes available.

Can I request a paper form to be placed on UW Health public site so patients can fill them out before a visit?

All medical record documents must be approved by HIM - Enterprise Content Management (ECM) before they can be placed on the UW Health public site (uwhealth.org). The reason for this is to ensure that the most current form is being used and linked to a primary source for the document (within the Medical Records Forms Library).

How do I know if my documentation templates in Health Link are compliant?

Health Link (HL) Team and HIM - Enterprise Content Management (ECM) will work with the clinical site manager when developing new and revised documentation tools in Health Link. The review and approval performed by the ECM team ensures that all content meets minimum requirements detailed in the Health Link Content Management and Style Guide, regulatory and accreditation requirements, as well as organizational policy.

I have a medical record form that I want created for use in my clinic/on my unit - how do I go about getting it created and approved?

The first thing that should be determined is if the information can be documented directly within Health Link. Paper forms creation is permitted only when documenting directly into Health Link has been evaluated and determined not to be an option. If a paper medical record form must be created, a ServiceNow ticket should be submitted and directed to HIM - Enterprise Content Management (ECM). ECM staff assigned to the ticket will contact you to begin the development/approval process. Regardless of format (paper or electronic), all documentation tools used for documentation in the medical record must go through the approval process.

How do I get a new patient questionnaire created?

All questionnaires need to be approved for use to ensure proper copyright permissions have been obtained. This review is conducted by the Questionnaire Workgroup in CCKM. Please contact CCKM to initiate review and approval for the use of a questionnaire. HIM - Enterprise Content Management (ECM) is then responsible for building the paper forms, or the Ambulatory Health Link team may be able to create an electronic version (subject to approval and priority determination).

I received an email from HIM indicating that I have been using an unapproved form. What should I do?

The email has been sent to you as you were identified as the clinic manager or you may know who may be using the unapproved form that was sent to HIM for filing/scanning into the medical record. Your timely assistance is greatly appreciated in getting this form through the approval process or directing Enterprise Content Management (ECM) to the correct person who can help. All documentation tools used for documentation within the medical record must go through the review/approval process.

What is the process for downtime forms?

HIM - Enterprise Content Management (ECM) team can assist with mocking up any forms you may need and store them within the Medical Records Library located under Downtime or Worksheets as appropriate. Please enter a ServiceNow ticket directed towards HIM-Enterprise Content Management or call HIM Supervisor at (608) 203-4884. First please check the policies and procedure for downtime for your area; second check the current downtime forms before requesting a new form, and lastly if a downtime form is needed, please submit a ServiceNow ticket.

My clinic/unit uses forms that do not belong in the medical record. Is there anything that I should do with the form to ensure it doesn’t get filed in the chart?

Yes. The footer requires the following statement: “Worksheet Only- Not a Medical Record Document, DO NOT SCAN.”

If the form should be returned to your clinic/unit add the following to the footer: “Return to location (add department/clinic and mail code).”

Please ensure that these documents are not sent to HIM for scanning.

What are the requirements for paper forms design? How do I know what I can and cannot have on my forms?

Review the Forms Design Primer for requirements for UW Health approved forms. Also, the HIM -Enterprise Content Management (ECM) team is the only group that may build medical record forms to be filed in the UW Health medical record. This ensures that all minimum regulatory, accreditation and organizational policies are met.

The Forms Primer pertains to paper documents - where do I look to find guidelines for the minimum necessary for our electronic content tools?

See the Health Link Content Management and Style Guide. All content built in the UW Health electronic health record must follow these guidelines.

What should I do if a smartlink is not working properly with a smarttool I am using?

Enter a ServiceNow Request with the hyperlink so it can be fixed.

What should I do if a URL hyperlink does not work within the electronic content I am using?

Enter a ServiceNow Request with the hyperlink so it can be fixed.

What types of electronic content needs review and approval?

HIM - Enterprise Content Management (ECM) has responsibility for reviewing and approving all system level build of all documentation tools. A ServiceNow ticket needs to be opened for ECM. ECM will review and approve the information.

Who do I contact if I have specific questions about electronic content and/or forms approval process?

Call the HIM Supervisor at (608) 203-4884 or submit a ServiceNow ticket directed to HIM- Enterprise Content Management.

As paper forms convert to electronic documentation in Health Link, is there anyone that should be notified that the paper form is no longer used?

Yes, please let HIM-Enterprise Content Management (ECM) know by submitting a ServiceNow ticket. Provide the form title of the form and the form number (bottom left corner of the form). ECM will work on deactivating the form once the ServiceNow ticket is received.

Can content be created within Health Link that contains a manual signature for either the clinician or patient to sign?

Health Link is only able to collect a manual signature electronically for registration at this moment. This project is continually being work on. Any other documentation that requires a manual signature needs to remain on paper.

Can I request a Consent Form to be created in Health Link and have a patient sign it electronically during a visit?

Consent to treatment and HIPPA acknowledgement forms are available by electronic signature for Registration. Other consents still remain on paper until functionality becomes available.

Can I request a paper form to be placed on UW Health public site so patients can fill them out before a visit?

All medical record documents must be approved by HIM - Enterprise Content Management (ECM) before they can be placed on the UW Health public site (uwhealth.org). The reason for this is to ensure that the most current form is being used and linked to a primary source for the document (within the Medical Records Forms Library).

How do I know if my documentation templates in Health Link are compliant?

Health Link (HL) Team and HIM - Enterprise Content Management (ECM) will work with the clinical site manager when developing new and revised documentation tools in Health Link. The review and approval performed by the ECM team ensures that all content meets minimum requirements detailed in the Health Link Content Management and Style Guide, regulatory and accreditation requirements, as well as organizational policy.

I have a medical record form that I want created for use in my clinic/on my unit - how do I go about getting it created and approved?

The first thing that should be determined is if the information can be documented directly within Health Link. Paper forms creation is permitted only when documenting directly into Health Link has been evaluated and determined not to be an option. If a paper medical record form must be created, a ServiceNow ticket should be submitted and directed to HIM - Enterprise Content Management (ECM). ECM staff assigned to the ticket will contact you to begin the development/approval process. Regardless of format (paper or electronic), all documentation tools used for documentation in the medical record must go through the approval process.

How do I get a new patient questionnaire created?

All questionnaires need to be approved for use to ensure proper copyright permissions have been obtained. This review is conducted by the Questionnaire Workgroup in CCKM. Please contact CCKM to initiate review and approval for the use of a questionnaire. HIM - Enterprise Content Management (ECM) is then responsible for building the paper forms, or the Ambulatory Health Link team may be able to create an electronic version (subject to approval and priority determination).

I received an email from HIM indicating that I have been using an unapproved form. What should I do?

The email has been sent to you as you were identified as the clinic manager or you may know who may be using the unapproved form that was sent to HIM for filing/scanning into the medical record. Your timely assistance is greatly appreciated in getting this form through the approval process or directing Enterprise Content Management (ECM) to the correct person who can help. All documentation tools used for documentation within the medical record must go through the review/approval process.

What is the process for downtime forms?

HIM-Enterprise Content Management (ECM) team can assist with mocking up any forms you may need and store them within the Medical Records Library located under Downtime or Worksheets as appropriate. Please enter a ServiceNow ticket directed towards HIM-Enterprise Content Management or call HIM Supervisor at (608) 203-4884. First please check the policies and procedure for downtime for your area; second check the current downtime forms before requesting a new form, and lastly if a downtime form is needed, please submit a ServiceNow ticket.

My clinic/unit uses forms that do not belong in the medical record. Is there anything that I should do with the form to ensure it doesn’t get filed in the chart?

Yes. The footer requires the following statement: “Worksheet Only- Not a Medical Record Document, DO NOT SCAN.”

If the form should be returned to your clinic/unit add the following to the footer: “Return to location (add department/clinic and mail code).”

Please ensure that these documents are not sent to HIM for scanning.

What are the requirements for paper forms design? How do I know what I can and cannot have on my forms?

Review the Forms Design Primer for requirements for UW Health approved forms. Also, the HIM -Enterprise Content Management (ECM) team is the only group that may build medical record forms to be filed in the UW Health medical record. This ensures that all minimum regulatory, accreditation and organizational policies are met.

The Forms Primer pertains to paper documents - where do I look to find guidelines for the minimum necessary for our electronic content tools?

See the Health Link Content Management and Style Guide. All content built in the UW Health electronic health record must follow these guidelines.

What should I do if a smartlink is not working properly with a smarttool I am using?

Enter a ServiceNow Request with the hyperlink so it can be fixed.

What should I do if a URL hyperlink does not work within the electronic content I am using?

Enter a ServiceNow Request with the hyperlink so it can be fixed.

What types of electronic content needs review and approval?

HIM - Enterprise Content Management (ECM) has responsibility for reviewing and approving all system level build of all documentation tools. A ServiceNow ticket needs to be opened for ECM. ECM will review and approve the information.

Who do I contact if I have specific questions about electronic content and/or forms approval process?

Call the HIM Supervisor at (608) 203-4884 or submit a ServiceNow ticket directed to HIM- Enterprise Content Management.

Resources

Forms

Guides

Content Management and Style Guides

Policies and Procedures

Abbreviation Listing

UW Health Medical Record Documentation

Medical Records

UW Health Approved Abbreviation List