Document Classification: Clinical Document — Operative Note

• Operative Note
• Operative Report
• Procedure Note
• Pre-operative diagnosis
• Post-operative diagnosis
• Date of Surgery
• Surgeon Name
• Description of Procedures

 

From the Process Document page

1. From the document task, scroll down to the bottom of the document image.
2. Click Process Document below the document image to display the Process Document page.
   Thumbnails of all the pages that were uploaded with this document are displayed horizontally across the top of the screen.
   Note: The Process Document link only appears for faxed documents or uploaded documents that have a file type of .pdf or .tiff.
3. Class — Select a document classification.
4. Click Save.

From the Actions section of a document task

Note: You can reclassify any document in REVIEW, SUBMITTED, or CLOSED status, assigned to PRACTICE or to any practice user.

1. In the patient chart, click the Find tab at the top of the list of chart tabs to search for and select the document you need.
2. At the bottom of the document, click view actions.
3. Click the Reclassify document option and select the new classification from the menu.
   Note: If you do not see this action, click more actions. Additional options appear.
4. Click Save. The document task is reclassified according to your selection.

 

If a document has blank or incorrect fields (such as the wrong patient name, classification, or provider) and you can see the correct information in the document image, you can return the document to athenaError so that athenahealth can correct the issue and reprocess the document for you.

1. Display the document.
2. Scroll down to the very bottom of the screen, just above the Save and Cancel buttons, and click view actions.
3. If the athenaError option is not visible, click more actions.
   
   
4. Select the athenaError option.
   
   The Action note field turns yellow.
5. Action note — Enter an action note to indicate why the document is being returned (for example, incorrect patient name, classification, etc.). This note is required so that athenahealth knows what corrective action to take.
6. Click Save.

 

Document labels are used for clinical and administrative documents in athenaClinicals.

 

Chart readability starts with good document labeling. A document label tells the user what a document contains without requiring the user to open it. Patient charts that lack clear, structured labels make it difficult for providers to quickly understand details of the patient's history and efficiently locate the documents that they care most about. For these reasons, athenahealth requires all incoming documents to have a quality label.

Note: The majority of documents received by interface and more than half of documents processed by athenahealth already have a quality label before you receive them and do not require further labeling.

1. Display the Process Document page: In the Clinical Inbox, select Type from the View by: menu at the top of the Inbox. Click the Unknown Documents row, and then click the faxed document to process.
2. Document Label — Click Select a document label to open the document label selector.
   
3. If you do not find an appropriate label in the Frequently used document labels section of the document label selector, search the full list of labels using the search bar at the top of the selector, and select a label for the document.
4. If you cannot find an appropriate label after searching the full list of labels:
   1. Click the Document label not listed link at the bottom of the selector.
      Note: To suggest additions to the global document label list, open a support case by selecting Support > Create Case or Call in the Main Menu.
   2. Internal Note — Enter a description of the document in this field.

 

All document classifications require a document label. When a tie-to-order (TTO) is available and tied to an open order by athenahealth or by your practice, the document label is added automatically. Otherwise, your practice must enter a document label.

Tip: You can create a task assignment override to route this responsibility to your staff.

 

The following document classifications can be tied to orders:

• Clinical Document — Consult Note
• Clinical Document — Mental Health Consult
• Clinical Document — Operative Note
• Imaging / Diagnostic Result
• Lab Result

• Physician Authorization — Care Plan Oversight

 

athenahealth follows these rules when tying an open order:

1. The ordering ("to") provider matches the provider on the document and TTO
2. The order date is on or before the collected/procedure date (orders tied within one year)
3. The order matches the content of the document

When an order is tied to an incoming result, reviewed, and closed by the provider, this closes the loop for the order, but the order remains available to tie to future results. The order will generate an athenahealth action note to notify you what document ID it was tied to.

 

Future orders cannot be tied. Please ensure that when you create a tie-to-order, it is prior to, or same day as, the date of service.

 

Note: Tying a lab result document to an order may take up to 120 days, and tying imaging / diagnostic results and any clinical documents to open orders may take up to a year.

 

How does a result appear in the patient chart when tied to an order?

When a result is tied to an open order, the order type appears in the patient chart (noted as generated in athenaOne), followed by the date of service. If the Date of Service field in the tied document is left blank, the patient chart shows the date the results were received. Internal notes appear below the order type and date.

 

The test result appears to the left of the order type. If the result document was received through interfacing, the test result is marked either Abnormal or Normal. If the result document was received through faxing, the test result is marked as Unknown.

 

athenahealth processes documents by patient name, so all results related to an order appear as tied to the appropriate order.

 

The athenaClinicals Document Processing Service uses default task assignments when your incoming documents are processed and sent to your Clinical Inbox.

 

After athenahealth processes documents, by default the documents are assigned to the username of the provider who was data-entered for that document, in REVIEW status.

 

If athenahealth cannot determine the document's provider, athenaOne uses your practice's default document routing configuration to route the document to either the Usual provider selected on the patient's Quickview page, or the STAFF queue of the practice or department to which the document was faxed.

 

If your practice uses the Provider-Centric Staff feature, athenahealth routes unknown documents to practice staff; otherwise, athenahealth routes unknown documents to department staff.

 

You can use the Task Assignment Overrides page to create alternate routing rules specific to your practice.

 

 

As your co-sourcing partner, athenahealth is responsible for processing all documents received from external providers (pharmacies, labs, hospitals, etc.), all documents transferred between departments in the same organization, and all documents sent via athenaFax to other practices that also use athenaClinicals.

 

Inbound documents processed by athenahealth appear in the documents section of the associated Patient Chart and in your Clinical Inbox for review. Lab and imaging results are matched to their associated orders.

 

Your practice is responsible for processing all documents sent from your practice to athenahealth (including documents received via mail/courier, documents brought in by the patient, as well as any documents generated within the practice as part of or ancillary to the patient encounter).

 

Department	The department receiving the records.
Patient Name/ID	The patient's name or ID number related to the document.
Class	The classification of the document.
Document Label	Any document labels you add to the document.
Observation Date & Time	The date and time of the consultation.
Internal Note	Any note you add to the document.
Provider	The provider receiving the records.
Clinical Provider	The facility or provider sending the records.

 

Document Classification	Availability
Admin	athenahealth
Admin — Billing	athenahealth
Admin — Consent	practice-only
Admin — HIPAA/Privacy	practice-only
Admin — Insurance Approval Notification	athenahealth
Admin — Insurance Card	athenahealth
Admin — Insurance Denial Notification	athenahealth
Admin — Legal	athenahealth
Admin — Medical Records Request	athenahealth
Admin — Referral	athenahealth
Admin — Signed Forms and Letters	practice-only
Clinical Document	athenahealth
Clinical Document — Admission/Discharge Summary	athenahealth
Clinical Document — Consult Note	athenahealth
Clinical Document — Emergency/Urgent Care Note	athenahealth
Clinical Document — Mental Health Consult	athenahealth
Clinical Document — Operative Note	athenahealth
Encounter Document — Authorization	practice-only
Encounter Document — Health History Questionnaire	practice-only
Encounter Document — Image Documentation	practice-only
Encounter Document — Procedure Documentation	practice-only
Encounter Document — Progress Note	practice-only
Imaging/Diagnostic Result	athenahealth
Lab Result	athenahealth
Medical Record Document — Chart for Abstraction	practice-only
Medical Record Document — Flowsheet	practice-only
Medical Record Document — Growth Chart	practice-only
Medical Record Document — Historical Medical Record	athenahealth
Medical Record Document — Patient Diary	athenahealth
Medical Record Document — Vaccination Record	athenahealth
Order (Already Signed)	Practice-only
Phone Message	athenahealth
Physician Authorization	athenahealth
Physician Authorization — Care Plan Oversight	athenahealth
Prescription — Change	athenahealth
Prescription — Clarification	athenahealth
Prescription — New	athenahealth
Prescription — Prior Authorization Request	athenahealth
Prescription — Renewal	athenahealth