STANDARD OPERATING PROCEDURE (SOP) FOR CLINICAL RESEARCH TITLE: Research Documentation Last Revised: 5/2017 Prior Version: None SOP NUMBER: SC- 403 Page 1 of 9 Developed by the UH Clinical Research Center SOP Committee 1 1. PURPOSE: To establish documentation standards for clinical research projects to ensure applicable safety, compliance, and billing requirements are met. 2. SCOPE: All entities conducting clinical research within the University Hospitals Health System. 3. RESPONSIBLE INDIVIDUALS: Clinical and research personnel who interact or care for clinical research participants. 4. DEFINITIONS/ACRONYMS: DOS - Date of Service EMR – Electronic Medical Record Enrollment/enrolled - generally means a research subject has been consented and screened, with eligibility verified GCP - Good Clinical Practice. Good Clinical Practice (GCP) is an international ethical and scientific quality standard for the design, conduct, performance, monitoring, auditing, recording, analyses and reporting of clinical trials. It also serves to protect the rights, integrity and confidentiality of trial subjects HIPAA - Health Insurance Portability and Accountability Act ICF - Informed Consent Form ICH - International Conference on Harmonization. Launched in 1990, ICH is a unique undertaking that brings together the drug regulatory authorities and the pharmaceutical industry of Europe, Japan and the United States. Licensed Medical Provider – An individual, such as a, physicians, nurse practitioners, or other health care professional with documented qualifications and/or licensure to perform medical related tasks (i.e. medical exam, review safety reporting, writing orders for procedures, prescribing medications, etc.) Medical Record - Paper or electronic source document repository of care provided to and patient status. Includes, but not exclusive of, the following: Allscripts Sunshine Enterprises [UHCare Ambulatory –Ambulatory Electronic Medical Record (aEMR)] & UHCare Acute– In Patient Electronic Medical Record; Community Record; Ensite; Mosaic (Radiology); Physician Portal Research - A systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge. 45 CFR 46.102
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STANDARD OPERATING PROCEDURE (SOP) FOR CLINICAL RESEARCH
TITLE: Research Documentation
Last Revised:
5/2017
Prior Version: None
SOP NUMBER: SC- 403 Page 1 of 9
Developed by the UH Clinical Research Center SOP Committee 1
1. PURPOSE:
To establish documentation standards for clinical research projects to ensure applicable
safety, compliance, and billing requirements are met.
2. SCOPE:
All entities conducting clinical research within the University Hospitals Health System.
3. RESPONSIBLE INDIVIDUALS:
Clinical and research personnel who interact or care for clinical research participants.
4. DEFINITIONS/ACRONYMS:
DOS - Date of Service
EMR – Electronic Medical Record
Enrollment/enrolled - generally means a research subject has been consented and screened,
with eligibility verified
GCP - Good Clinical Practice. Good Clinical Practice (GCP) is an international ethical and
scientific quality standard for the design, conduct, performance, monitoring, auditing,
recording, analyses and reporting of clinical trials. It also serves to protect the rights,
integrity and confidentiality of trial subjects
HIPAA - Health Insurance Portability and Accountability Act
ICF - Informed Consent Form
ICH - International Conference on Harmonization. Launched in 1990, ICH is a unique
undertaking that brings together the drug regulatory authorities and the pharmaceutical
industry of Europe, Japan and the United States.
Licensed Medical Provider – An individual, such as a, physicians, nurse practitioners, or
other health care professional with documented qualifications and/or licensure to perform
medical related tasks (i.e. medical exam, review safety reporting, writing orders for
procedures, prescribing medications, etc.)
Medical Record - Paper or electronic source document repository of care provided to and
patient status. Includes, but not exclusive of, the following: Allscripts Sunshine
Enterprises [UHCare Ambulatory –Ambulatory Electronic Medical Record (aEMR)] &
UHCare Acute– In Patient Electronic Medical Record; Community Record; Ensite;
Mosaic (Radiology); Physician Portal
Research - A systematic investigation, including research development, testing, and
evaluation, designed to develop or contribute to generalizable knowledge. 45 CFR 46.102
STANDARD OPERATING PROCEDURE (SOP) FOR CLINICAL RESEARCH
TITLE: Research Documentation
Last Revised:
5/2017
Prior Version: None
SOP NUMBER: SC- 403 Page 2 of 9
Developed by the UH Clinical Research Center SOP Committee 2
Source Data - All information in original records and certified copies of original records of
findings, observations, or other activities in a clinical trial necessary for the
reconstruction and evaluation of the trial. Source data are contained in source documents
(original records or certified copies)
Source Document - Original documents, data, and records (e.g., hospital records, clinical
and office charts, laboratory notes, memoranda, subjects' diaries or evaluation checklists,
pharmacy dispensing records, recorded data from automated instruments, copies or
transcriptions certified after verification as being accurate and complete, microfiches,
photographic negatives, microfilm or magnetic media, x-rays, subject files, and records
kept at the pharmacy, at the laboratories, and at medico-technical departments involved in
the clinical trial)
5. POLICY STATEMENT:
Accurate and complete documentation is the cornerstone of Good Clinical Practice (GCP)
and permits an observer to recreate a subject’s participation in a research study and to
account for the use of any investigational products.
Source documentation must be kept in accordance with FDA regulations (21 CFR 11, 21
STANDARD OPERATING PROCEDURE (SOP) FOR CLINICAL RESEARCH TITLE: Research Documentation
Last Revised: 5/2017 Prior Version: None
SOP NUMBER: SC- 403 Page 3 of 9
Developed by the UH Clinical Research Center SOP Committee 3
B. Research Registration/Scheduling 1. All research subjects seen onsite at UH facilities must be registered and given
a medical record number if they don’t already have one. “Research insurance” must be placed in the primary insurance position for any clinical study-related DOS, in accordance with UH Policy R-2 Patient Billing under Research Grants.
i. The registration process for a new UH patient assigns them a singleunique medical record number in accordance with UH Policy GM-71 – Patient Access Service (PAS).
2. Research related appointments must be scheduled in the hospital or entityscheduling system.
i. Scheduling at University Hospitals Cleveland Medical Center(UHCMC) must occur in Athena and/or Soarian, depending uponwhether technical or professional patient care services will beprovided.
ii. Registration and scheduling instructions are located in Appendix C –“Registration Workflow: Athena/ Soarian Research Documentation”.
C. HIPAA and Research 1. Parts of the Health Insurance Portability and Accountability Act (HIPAA)
regulations are designed to ensure research patients’ privacy and the security of the information we use and retain within UHCMC and regional offices.
2. Researchers accessing, using or retaining protected health information (PHI) ofUHCMC patients must abide by the UHCMC’s HIPAA-related policies.
3. Restricted/Confidential Records follow organizational guidelines for restrictedrecords (i.e., Browns players, public figures, infectious disease and psychiatricpatients).
In accordance with UH Policy GM-61 Accessing Medical Records (Section 12.3 research records), PH-3 - Permitted Uses/ Disclosures of PHI (Section 2.11 – for research), PH-4 Authorizations for Use and Disclosure of PHI (Section 7.1 – Research), PH-23 – Psychotherapy Notes, R-3 Uses & Disclosures of PHI for Research.
E. Research Documents 1. All original source and essential research documents must be retained.
Measures should be taken to prevent any premature or accidental destruction.
STANDARD OPERATING PROCEDURE (SOP) FOR CLINICAL RESEARCH
TITLE: Research Documentation
Last Revised:
5/2017
Prior Version: None
SOP NUMBER: SC- 403 Page 4 of 9
Developed by the UH Clinical Research Center SOP Committee 4
2. A copy of research records should be maintained in the EMR if applicable per
institutional policy or at the discretion of the investigator to ensure adequate
subject safety.
3. When original observations are entered directly into a computerized system, the
electronic record is the source document. This requirement applies to the
retention of the original source document, or a copy of the source document.
In accordance with UH Policy GM-1 Records Management, ICH E6 4.9.4.b,
21CFR312.62 Investigator Record Keeping and Record Retention – Case histories, FDA
Guidance for Industry - Computerized Systems Used in Clinical Investigations: Source
Documentation and Retention.
D. Required Medical Record Documentation
In accordance with UH Policy CP50 – Worklist Documentation (including eMAR),
UH Policy EMR-1 Integrated Interdisciplinary Documentation and Charting in the
EMR, UH Policy GM-49 Medical Records Completion and UH Policy GM-93 –
Timely Completion of Transactions in the Ambulatory EMR.
1. All clinical study related tasks must be documented on a timely basis by the
clinician and/or delegate who performed the task.
2. Include secondary diagnosis code Z00.6 (research) on billing charge capture
documents for all care provided as documented below.
3. Assure that the following elements are documented in the patient medical
record:
i. Informed consent (IC).
In accordance with FDA 21 CFR 50.27: “Documentation of Informed
Consent”, and UH IRB Policy “Informed Consent”.
The IC process must be documented in the subject’s medical
record.
Refer to Appendix E: UH Clinical Research Tools and Templates
EMR Standard Filing Guide Master (Where to file scanned documents in the subjects’ EMR) https://intranet.uhhospitals.org/ClinicalProfessional/PhysicianServices/docs/UHCare_Policies/Sta
ndard_Filing_Guide.xlsx FDA Guidance for Industry: Electronic Source Data in Clinical Investigations
FDA 21 CFR 11: Electronic Records and Electronic Signatures
Matrix/ Clinical_Data_Matrix.pdf#search=clinical%20data%20matrix FDA BIMO Chapter 48: Biomedical Monitoring Program 7348.811
Ohio Code 4731-23-02 - Delegation of Medical Tasks
UHCare Link (Information for UHCare training manuals and job aids): https://intranet.uhhospitals.org/ApplicationsPortal/System/UHCare/Training2_Home.aspx
UH IRB Policy: Informed Consent
UH IRB Policy: Records
UH Policy CP-44: UHCare Training for Clinical Staff
Guide to Clinical Data Location (Clinical Data Matrix) The ability to connect with patient data across the UH system and affiliated hospitals is vital to continuity of care and patient
safety. The table provides a roadmap for patient data by source, type and location.
• At CMC, Patient Access Services (PAS) registers:
– Radiology
– Seidman
– Dahms Clinical Research Unit (DCRU) visits for
both RB&C and Coleman Clinical Research Suite
• Patients must be scheduled for billable
research services
– Hospital/technical (UHC, PMC, SJMC etc)
– Professional (UHMG)
– Not necessary to formally schedule
research personnel time only visits (e.g.
Study Coordinator or research nurse)
Registration v Scheduling – cont.
Research Registration - Athena
Registration team adds research “insurance”
Research Registration - Soarian
9/2014
February 7, 2012
Be the Difference.
Scan 1
UHCare Ambulatory Scan
UHCare Ambulatory Scan Overview
The Scan module is an electronic imaging and chart management application. It is used to transfer written documents such as consults, some test results, journal articles (for reference), and other pertinent chart information into an electronic format.
Scanned documents are indexed to the appropriate patient for the appropriate visit and under the correct document type.
Scanned documents may then be viewed from the Clinical Desktop.
UHCare Ambulatory Scan
Job Aid UHCare Ambulatory 2
Logging In to Scan
1. From the desktop, double-click the UHCare Ambulatory Scan icon.
The UHCare Ambulatory Scan Sign On page displays.
2. Enter your User Name and Password.
Your User Name is your UH Network User ID.
Your initial password is welcome01.
Note ► You must change your password manually the first time you access UHCare Ambulatory Scan by clicking Configure and Change Password.
3. Click Login.
4. Accept the Licensing Agreement, if necessary.
Note ► The User (or User Group) rights govern what is available to the Scan user. Certain buttons or pages may be grayed out or unavailable based on these rights.
UHCare Ambulatory Scan
UHCare Ambulatory Job Aid 3
Searching for Patients in UHCare Ambulatory Scan
1. From the Scan toolbar, select the Search Menu.
2. Select Patient Charts from the drop-down menu.
3. Complete the Patient and Type fields in the Patient Search page.
4. Click Search.
Tip ► Users may search for patients by Name, MRN, DOB, Phone, Other, or Bar Code.
5. On the Pick Patient page, select a patient name.
6. Click Select.
The Patient Chart displays with the Chart Group in the middle of the page.
7. To view a document in a chart, select the appropriate folder from the Chart Group.
8. Double-click the folder to open it.
Notes Regarding Folders
Empty Folders are gray.
Parent folders with content are gray/yellow.
Sub-folders with content are yellow.
System folders have a blue diamond.
UHCare Ambulatory Scan
Job Aid UHCare Ambulatory 4
Batch Scan with Tasking
The Batch Basket workflow is the preferred method when scanning similar document types for multiple patients.
Similar documents may be placed in a pile upon receipt and scanned in as a Batch Basket by anyone at the end of the day. Once all documents are scanned, they must be sorted to the appropriate patient chart.
Recommended batch size is less than 50 pages.
1. From the Scan toolbar, click Batch.
2. Select Scan.
3. From the Batch Scan Documents page, enter a name for the batch.
Note ► Batch names should be intuitive to the document type and contain your 4 letter code for your practice. (This is the same code as entered into ImpactMD and Athena).
Tip ► The Default Document Name and Default Document Date are default values and may be changed while sorting to a patient’s Chart Group folder.
4. Set the Access Group to limit access to this batch to specific groups of users, if necessary.
5. Click Scan to begin scanning the batch.
6. Click Sort to Chart to sort images to patient charts.
7. Manipulate the image as necessary to identify the document type and identify the patient.
8. Enter Name of the Patient (Last Name first) in Patient field.
9. Click Search.
10. Select the patient.
11. Click on ellipsis next to the Current Folder field to display the Folder Tree Window.
12. Click the appropriate folder to file this document.
13. Click OK.
14. Enter the Document Date, if not, enter today’s date.
15. Verify that the owner of the document is the Provider.
UHCare Ambulatory Scan
UHCare Ambulatory Job Aid 5
16. If the owner is incorrect, then click the ellipsis (three dots) button next to the Encounter field and choose the correct encounter.
Note ► By choosing the correct encounter, the correct owner will automatically fill in.
17. To task this document to the Provider for electronic signature, choose the Send Review Task to Owner in TouchWorks button, if necessary
18. Click File Document.
19. Click [Page 2] if the current document is an additional page to the last document that was filed.
20. If all remaining pages belong to the same document, click File Remaining Pages to include the remaining images as additional pages.
21. Repeat steps 9-19 to complete the batch scanning.
22. Close (door) when completing batch scanning and close again to get to initial screen.
Filer Scan with Tasking
The Filer workflow is the preferred method when scanning multiple documents of different types for a single patient.
The Filer workflow may also be used when scanning a single document type for a single patient. Using this method images are scanned into the specific folder, thus eliminating the need for the filer to indicate document type.
1. Place the document in the scanner.
2. Log in to Scan.
3. Click Search.
4. Select the patient.
5. Count your pages before you begin.
Tip ► While the scanner can scan up to 50 pages at a time, it is recommended that you don’t scan more than 30 at a time to avoid jamming.
6. From the Scan toolbar, click the Scan button .
Tip ► The patient information displays in the Chart#, SSN, and Name fields.
UHCare Ambulatory Scan
Job Aid UHCare Ambulatory 6
Note ► All documents will be scanned into the To be filed folder. The Document Name and Date fields default to the system date and folder.
7. Select the Duplex option if scanning double-sided documents.
Note ► If using a flatbed scanner, the user is prompted to continue scanning after each page.
8. Click Scan.
Note ► When scanning is complete, the application returns to the patient chart and the To Be Filed folder contains the scan job.
9. Click Filer to file documents to the Chart Group folders for the patient.
10. Manipulate the image as necessary to identify the document type and identify the patient.
11. Confirm that the document type and date are correct.
12. Change the date to match the date of the document being scanned.
Note ► The document date defaults to the scan date.
13. If the document needs to be electronically tasked to the Provider for an electronic signature, complete the following steps:
a. Click New Task (icon with the circular arrow) on the Scan Toolbar
The Create New Task window displays.
b. From the Category drop-down, select Verify or Sign.
c. Click To .
d. In the Type Name field, enter the Provider’s name.
e. Click once on the Provider’s name.
f. Click To-> in the middle.
Note ► The Provider’s name should show on the right side.
UHCare Ambulatory Scan
UHCare Ambulatory Job Aid 7
g. Click OK.
h. In the Reply To drop-down, verify that the sender’s name displays.
i. Enter a short description of the document or message being sent, if desired.
j. Click Send to send the task and return to the Document Viewer.
Note ► Once the task is sent, it displays on the Task List in UHCare Ambulatory for follow-up.
k. Set the status of the task using the buttons at the top of the window:
The default is set to Normal, no icon required.
The red exclamation point denotes Urgent.
The blue arrow means Low Priority.
14. Click the sub-folder button to file the scanned image as the selected document type.
15. Click [Page 2] if the current document is an additional page to the last document that was filed.
16. If all remaining pages belong to the same document, click File Remaining Pages to include the remaining images as additional pages.
Note ► The association between the image and selected document type is not finalized until the page is closed.
Tip ► Any images not filed will remain in the To Be Filed folder.
Searching for a Document in UHCare Ambulatory Scan
1. From the Scan toolbar, select the Search Menu.
2. Select Documents from the drop-down menu.
3. In the Document Search window, enter your search criteria.
The Document tab enables a user to enter document specific search criteria by: Document Number, Document Date, Document Name, Acquire (Scan) Date, Last Change, Chart Group, and Folder.
The Chart tab enables a user to enter patient specific search criteria by: Site, Patient, and Type.
4. Click Search.
5. Click Clear to clear the search tabs and search again.
Tip ► To re-access recent patient charts, from the top toolbar select Chart Lists and then Recent from the drop-down menu.
UHCare Ambulatory Scan
Job Aid UHCare Ambulatory 8
Viewing a Document in UHCare Ambulatory Scan
1. To work with a document in Scan, bring a patient into context.
2. Select the appropriate folder from the Chart Group.
3. Double-click a document to open it in the Document Viewer.
4. To manipulate the scanned image, use the toolbar at the top of the Document Viewer.
Document Viewer Toolbar Options
Informed Consent Documentation Checklist
Protocol Title:
IRB Number: Principal Investigator:
Version 5/2017
Study ID: _______________________ Study Visit Date: _____________________________ (Month /Day/Year)
Date of first contact with participant regarding study: __________________________________
Catheterization Catheterization documentation and results
Doppler Doppler documentation and results
Echo Echo documentation and results
EKG EKG documentation and results
Monitors Cardiovascular Monitoring data and documentation
Stress Test Stress Test documentation and results
CV Devices Cardiovascular device documentation
Initial Interrogation Report
Mechanical Assist Device and Lead Information sheet
PST Meter Training
Pulse Width Threshold Test
Other CardiovascularCardiovascular Testing documentation and results other than those categorized above
Gastro Testing Gastro Testing
Colonoscopy Colonoscopy documentation and results
Endoscopy Endoscopy documentation and results
Barium Swallow Barium Swallow documentation and results
EGD EGD device documentation
Other GastroGastro Testing documentation and results other than those categorized above
Neurology Neurology
EEG EEG documentation and results
EMG EMG documentation and results
Other NeurologyNeurology documentation and results other than those categorized above
Pulmonary Testing Pulmonary Testing
Bronch Bronch documentation and results
Sleep Study Epworth Sleepiness Scale/ ESS
Sleep Questionnaire
Sleep Study documentation and results
PFT/Spirometry PFT and Spirometry documentation and results
Other Pulmonary Pulmonary Testing documentation and results other than those categorized above
Other Testing Speech Therapy
Testing information that doesn't go into any other folder listed.
Voice evaluations
Vision Vision testing documentation and results
Advanced Diagnostic tests Advanced Diagnostic testing information
Audiology Hearing test documentation and results
Hearing Aid/Spec Devices Hearing aid and device information
Cochlear Implant Cochlear Impact information
Allergy Allergy
Skin Testing Skin Testing documentation
Patient Formula Immunotherapy form RX
Patient Formula sheet
Shot Chart Antigen Shot Record
Immuno-Progress sheet
Shot Reaction Record
Venum Shot record
Xolair/ IVIG Xolair/ IVIG forms
PATIENT INFORMATION ABN Patient ABN Consent Forms
Consent Forms Contract for Controlled Substance Prescriptions
Other Patient Consent Forms
DNR/DNI/Directives Advanced Directives
HIPAA HIPAA-related documentation
Living Will Patient's living will
POA Power of Attorney
Registration Forms Patient Registration Forms
ROI Release of Information Forms
Other Patient Information Other patient forms that do not match any of the above folders
CORRESPONDENCE Patient Patient
FMLA FMLA case documentation
Physical Forms Patient Physical documentation
Disability Disability Claim forms and documentation
Insurance Patient insurance documentation
Medical Records/Record ReleasMedical Record Release Forms and requests
Legal Legal forms and documentation
BWC Miscellaneous BWC documents not listed below
C9 C9 Forms
First Report of Injury First Report of Injury Forms
Medco 14 Work Ability Frm Medco 14 Forms
C23 Change Phys of Record C23 Forms
Medco 31 Prior Auth Meds Medco 31 Forms
DOT Forms DOT Forms
BWC Clinical Notes BWC Visit Notes/documentation
MRO Verification MRO Verification Forms
Incident Report BWC Incident Reports
Miscellaneous Miscellaneous Correspondence
Surgery Reservation Request
Rehab/Home Health Home Health Visit Notes
PT/OT
DME Certification DME Certification forms
Multidisciplinary Notes Craniofacial notes
Social Work Social Work
Dietary Dietary
OLD RECORDS OLD RECORDSTransfer records sent from a different practice. Usually proceeded by an Authorization to release information
MISFILED MISFILEDDocuments in the wrong patient's chart that have been electronically signed by the physician
DATA SOURCE DATA TYPEPhysicianPortal
Community Record*
State HealthInformationExchange (HIE)
UHCare Acute EMR
UHCare Ambulatory
EMR
UH PersonalHealth
Record (PHR) OTTR
Demographics (ADT) ‐ Downtime Only x x xAllergies x x x
History & Physical x x xProgress Notes x
Consults x x xDischarge Summary x x x
Oncology Notes (Ambulatory) x x xCoordinated Care Notes x x xMedication Reconciliation x x
C‐CDA x x
CCD x x xOffice Visit,
Health Maintenance,Dietitian, Medicare, PharmD,
PPD Result, Procedure Notes
x x x
Athena Registrations (ADT) x x x x x xCardioLab (PRUKA) Adult Electrophysiology x x x x
CoPath Pathology x x x x x xSyngo Peds ECHO x x x X xEmbla Sleep Lab Studies x xHeartlab Adult Cath/Vascular/Stress x xSyngo Adult ECHO X X X X XIDX Rad Radiology Reports (textual) x x x x x x xMedgis Genetics Reports x x
MedQuist Transcriptions (unsigned) x x x xMeta Demographics, Dx, Px x x x
Meta (eSig) Transcriptions (signed) x x xMuse EKG wave reports x x
Provation GI Documents x x x (select results) x x xSoarian Demographics (ADT) x x x x xSoftlab Lab Results x x x x x x xSoftlab Microbiology x x x x xSpheris Transcriptions x x x x
Viewpoint Ultrasounds x x x
The ability to connect with patient data across the UH system and affiliated hospitals is vital to continuity of care and patient safety. The table below provides a roadmap for patient data by source, type and location. If you have any questions, please contact the Clinical Portals team at [email protected].
DATA RESIDES IN:
UHCare Acute EMR
UHCare Ambulatory EMR
Revised: 10‐15‐15
UHCare Acute EMR
UHCare Ambulatory EMR
UH Ancillary Systems
DATA SOURCE DATA TYPEPhysicianPortal
Community Record*
State HealthInformationExchange (HIE)
UHCare Acute EMR
UHCare Ambulatory
EMR
UH PersonalHealth
Record (PHR) OTTR
DATA RESIDES IN:Revised: 10‐15‐15
Orchard Harvest Lab Results x
McKesson Demographics (ADT) xCerner Lab Results and Microbiology xSeris RIS Radiology Reports X
Dictaphone/Horizon Transcribed Notes X
Demographics (ADT) xRadiology Reports xTranscriptions x
Lab Results and Microbiology x
Soarian Demographics (ADT) xDictaphone Radiology Notes xSiemens EDM Transcriptions x
SoftLab Lab Results and Microbiology x
Demographics (ADT) xRadiology Notes xTranscriptions x
Lab Results and Microbiology x
Demographics (ADT) xLab Results x
Transcribed Notes xMedications x
Demographics (ADT) xLab Results x
Transcribed Notes xMedications x
Demographics (ADT) xLab Results x
Portage Medical Center
Data from Other FacilitiesUniversity Suburban Health Center (Green Rd.)
Parma Medical Center
Mercy Medical Center
Meditech
Meditech
Meditech
Elyria Medical Center
Southwest General Health Center
Cerner
St. Vincent Charity Hospital
St. John Medical Center
Meditech
DATA SOURCE DATA TYPEPhysicianPortal
Community Record*
State HealthInformationExchange (HIE)
UHCare Acute EMR
UHCare Ambulatory
EMR
UH PersonalHealth
Record (PHR) OTTR
DATA RESIDES IN:Revised: 10‐15‐15
Transcribed Notes xMedications x
* In the UHCare Ambulatory EMR, access Community Record by selecting the “Community” button at the bottom on the Clinical Desktop. In the UHCare Acute EMR, select the “Community Record” tab.