When a trainee enters an ambulatory referral order a supervising/staff physician must be entered in the By Provider field. 

• While trainees can enter and sign referral orders, a supervising physician must be named as the referring provider for Internal and Outgoing referrals. 

• Failure to enter the name of a supervising physician will prolong the processing of the referral and may lead to the referral being rejected. 

STEPS FOR ENTERING AN AMBULATORY REFERRAL

Admitted patient 

Ambulatory referrals that will be fulfilled outside of the building or at a future date after discharge are entered as an external order. Steps are:

1. Go to the Orders activity tab

2. Then to external orders (since it is outside the walls of your building)

3. Click + new order

4. Enter "ambulatory referral"

   • • this will bring up the alphabetical list of all referral services by specialty. 

     • select the appropriate one or refine your search term to a specific specialty.

5. The window that opens after accepting the service has fields to enter specifics for the referral.

   • The first step is to confirm if this is an Internal or External referral. Internal referalls are to an AHS ambulatory clinic, External referrals are to community providers. 

   • In the By Provider field please enter the name of your supervising physician or the appropriate attending physician. More information about By Provider is included in the section below.

6. Select the appropriate clinic.

7. Enter or select the appropriate reason for referral.

8. Click Accept 

9. Sign the order

Outpatient visit

To enter an ambulatory referral for a scheduled outpatient encounter, your steps are 

1. Enter "ambulatory referral" in the order entry field

   • • this will bring up the alphabetical list of all referral services by specialty. 

     • select the appropriate one or refine your search term to a specific specialty.

2. After accepting the service a new window opens with fields to enter specifics for the referral.

3. The first step is to confirm if this is an Internal or External referral. 

   • • Internal referals are to an AHS ambulatory clinic, 

     • External referrals are to community providers. 

4. In the By Provider field please enter the name of your supervising physician or the appropriate attending physician.

5. Select the appropriate clinic.

6. Enter or select the appropriate reason for referral.

7. Click Accept 

8. Then Sign the order

Specifying the Referring Provider

Ambulatory referrals require a referring provider. The name of the referring physician is identified in the By Provider of the ambulatory referral order.

• While trainees can enter and sign referral orders, a supervising physician must be named as the referring provider for Internal and Outgoing referrals. 

• Identifying a staff physician in the By Provider field is required for the receiving clinic to schedule the appointment, to communicate information back to, and to follow up with if additional information is needed. 

• Not having a referring provider identified in the By Provider specified can result in the referral being rejected.

I cannot sign orders (when patient is located in Emerg)

When you are seeing a patient that is physically located in the emerg and you are responding to a consult order from a non-emerg service i.e., surgery or pulmonary medicine, then the system will ask for the Authorizing Provider. 

By default, all Orders that are entered by a resident have the Attending identified as the authorizing provider. This ensures that if lab results come in after the patient is discharged someone receives them. 

For Emerg patients that are being consulted the ED physician would not want to receive those results, so you have to identify who the appropriate Authorizing provider is.

If you are seeing this popup for patients not in the Emerg please contact the helpdesk and provide the MRN for an example patient so we can look into it. 

Sharing notes to NetCare and other providers 

In Connect Care outpatient notes are, by default, progress note that do not leave the system. For the note to be shared to Netcare, and/or copied to other clinicians, an extra step is required. 

That is to use the Communication function to specify the note is to be shared as a letter and to select with whom to share the note. 

Steps to route note as a Consult Letter

1. After completing the note, click Accept,

2. In the This Visit activity tab, find find the Communications panel,

3. Click +New Communcation,

4. Select the recipint(s),

5. Use one of the available quick buttons that has Netcare in the title to select a communication template, The Consult Netcare letter template is suggested

6. Review the letter (optional),

7. Double check that default Send At Sign Visit is enabled, if desired can use Send Now to have the letter uploaded now.

Send Notes "Quick Click" 

Prescribers who document the content of an outpatient consultation in the encounter progress note can instantly mark that note for sharing using the Send Notes option that appears at the top of the Note sidebar panel.

• Selecting Send Notes replaces, with one click, the multiple steps outlined above. 

No PCP

Communications assume that there is a recipient, usually a primary care provider and/or referring provider. However, there may be situations when a letter should route to Netcare when no primary care or referring provider is specified. Any of the following actions will work when default recipients are not available:

Emergency Provider

• The patient may have been referred from an emergency encounter. The relevant emergency room prescriber can be entered as a "referring provider" before the communications activity is initiated. Communications can be routed to referring providers when there is no primary care provider.

Patient has no PCP

• Connect Care allows entering "Patient has no PCP" to as the recipient.

• "Patient has no PCP" can also be selected as a letter recipient even if not set as the patient's primary care provider. Use of a Netcare letter template will work but Connect Care will attempt a local print of the letter as well; avoidable by selecting "Print to PDF" and then not following through on the "save" part of the printing workflow.

Copy to self

• Letters can still be routed to Netcare without primary care or referring providers identified. One can copy the letter to oneself. The letter will go to Netcare and be copied to the Connect Care prescriber's In Basket.

External System Constraints

There are limits to what Netcare (and EMRs) can accept. Currently, documents are rendered to "pdf" format for external sharing and may not be accepted if the file size is too large.

Embedded Links

When viewed in an external system, the pdf document will not be part of the Connect Care record. Embedded links to Connect Care content will not work. Embedded links to Internet resources (hyperlinks) may not work in the receiving system.

Embedded Images

Avoid embedding images or other media that could increase the file size of shared documents. Image(s) are essential to clinical communication (e.g., rash), try to keep the image size small and do not embed more than 2 images.

Corrections and re-Writes

Once an outpatient letter goes to an external system it is not possible to edit and revise its contents. If necessary, the outpatient letter can be revoked (deleted) within the communications activity. This will send an appropriate message to Netcare. A new instance of the letter can then be created using an external systems template.

Notes authored by Trainees (resident/fellow) in the outpatient setting will be "owned" by the trainee, even after cosigning, editing, or attestation.

Cosign Other clinicians can see the note before it is cosigned, the status of Cosign Needed is shown. After it is cosigned by a supervising provider, the student appears as the author and the attending appears in the revision history.

Attest Supervising providers can add attestations directly to a trainee's note and the attestation verifies the note's content without having the provider take ownership of the note.

Edit Supervising providers can edit a note, the edit will not be identified in the same way that an attestation is but, edits are tracked and are displayed in the note revision history.

Addend After the note is signed, or cosigned, the text of the note can be Addended (updated). Addended text will not stand out in the same way that attestation will but, but edits are tracked and display in the note revision history

Routing notes as a Consult Letter

Outpatient notes are by default progress notes that do not leave the system. When outpatient visit is for a consult the Communication function is used to route that note to Netcare and/or to other providers. 

• When your note is used to create the Consult Letter you will appear as the note author in Netcare, not the supervising physician the patient is scheduled with.

Creating a new note "owned" by the Supervising Physician

If your staff wants to use your note for the consult letter they can:

• • Create a copy of your note, or make themselves the author of your note, then Use the Communication function to route the note to Netcare and selected recipients.

Copy and Create New Note

• Click edit on the note authored by the trainee

• At the bottom left of the note is an icon that looks like two overlapping pieces of paper

• This button will copy the note text and create a new note with the supervising physician as the author

• Add to the note as necessary

• Accept the note

• Make sure to select Send to PCP & referring, or use the Communication tool in the Wrap Up activity to have a Consult Letter sent to Netcare

• Once the visit is signed the letter will be routed to Netcare and the selected recipients

• The author of the note will be the supervising physician. 

Editing Signed Notes

Summative Documentation

When documenting at transitions of care, or at milestone events during an encounter, "summative" documentation is used to capture a snapshot of a patient's status. Summative documentation gathers information pertinent to an encounter, organizes observations, exposes meaning and offers a plan keyed to goals.

Summative Documentation Types

The following types of summative documentation are subject to AHS provincial standards (with expectations for style, headings and information ordering expressed in standard templates).

• Emergency Department Provider Note (summary of ED encounter)

• Admitting History and Physical

• Labour and Delivery Report

• Operative Report

• Consultation Report

• Discharge Summary

• Deceased Note (unique template applied within the Discharge Summary note type)

• Inter-facility Transfer Note (unique template applied within the Discharge Summary note type)

Note templates

Smartphrases have been developed to ensure summative notes align with AHS provincial standards. Below are the "dot phrases" that can be used to apply the note template for each type of note.

H&P Admission Note .ahsipbasicAdmit

Consult Note .ahsipbasicConsult

Discharge Summary .ahsipbasicDCSummary

Progress Note .ahsipbasicProgress

Upload to Netcare & PCP

Inpatient and Emergency Department summative notes are automatically uploaded to Netcare and sent to the patient's Primary Care Provider (PCP) when signed by the authoring trainee. 

• This routing takes place when the note is signed by the authoring trainee, even if a co-signature has not yet been completed.

• Routing to the PCP typically involves the note going to their community Electronic Medical Record (EMR)

• Where a PCP does not use an EMR it may be faxed to their clinic. 

Addending a Signed Note

Each time a note is edited, or Addended, then signed, the revised note is routed to Netcare and the PCP. 

There have been instances of community physicians receiving multiple versions of the same note.

• In Netcare the new note overwrites the old note

• For community EMR the new note does not overwrite, it is sent as a new message

• When sent by fax the entire note will be received and printed out 

Save or Pend vs Sign

When a summative note is Saved or Pended, it is visible to all in Connect Care but will not be uploaded to Netcare. 

• When authoring a note consider saving the note until you are certain that no additional changes will be required, then Sign the note.

Edit and Save

When editing, consider saving it until you are certain no additional changes are required, then Sign the note. 

Resident and Fellow Training - externalorder