Assessment Instructions

Prior to being scheduling for a Provider site, you must complete this assessment by following the steps below. Answer the questions and then retrieve entire document using the IronKey Retrieval Method. (AdobeReader is required. If you do not have Adobe Reader you can download a free copy at www.Adobe.com.)

STEP 1 COMPLETE THE ASSESSMENT

• Login to Web Center and locate the assessment on the bottom right hand corner.

STEP 2

SAVE THECOMPLETED ASSESSMENT TO YOUR DESKTOP

• Click File, choose Print. Under Select Printer choose an option that will give you anextension of .PDF .XPS. MDI or .TIF. Title your document ‘Assessment_YourLastName’.

• Click Print. If you cannot locate the File menu, click the print icon at the topleft corner of yourscreen and follow the instructions above.

STEP 3

RETRIEVE THEASSESSMENT FROM YOURPERSONALCOMPUTER USING THE IRONKEYFLASHDRIVE

AND

TRANSFER THEASSESSMENT TO YOUR CIOXLAPTOP

*NOTE: These steps simulate the retrieval of EMR documents from a Provider’s computer and the transfer of EMR documents to your CIOX Health laptop.

IRONKEY PASSWORD: Your initial password consists of the letters “ECSFd” followed by the“@” symbol, and your three digit equipment number (located above the keyboard on your ECS laptop). Example: ECSFd@123*NOTE: Your password is case sensitive.

LAPTOP PASSWORD: The password for your laptop consists of the word ‘Tech’followed by the ‘@’ symbol and the three digit equipment number on your laptop. Ex: Tech@123*NOTE: Your password is case sensitive. .

RETRIEVE THE ASSESSMENT – Follow the steps in the EMR to Flash Drive from the Field Tech Manual to save the assessment from your desktop to the Ironkey Flash Drive.

STEP 4

SCAN THEPRINTED ASSESSMENT USING THEPAPER SCAN METHOD

*NOTE: This step simulates the paper scan retrieval method.

PRINT THE COMPLETED ASSESSMENT: You should have all pages - the instruction sheet,the Dummy Medical Records (10 pages), and Test Cover Sheet.

SCAN THE DOCUMENT USING THE SCANNER: Scan the Test Cover Sheet and Dummy Medical Records. Follow the steps in the Scanning Paper Charts from the Field Tech Manual to complete the process.

STEP 5 UPLOAD THE

ASSESSMENT

*NOTE: This step simulates the upload process.• Use the Uploading from CIOX Health Laptop to CIOX Health from the Field TechManual to assist you through this process.

John Doe

Sample Medical Record Component-For Training Purposes Only 1

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Sample Hospital Patient Name: John Doe Room Number: 305 Attending Physician: Procedure: 88-379 Date of Procedure 4/5/98 Procedure: M Mode and 2D echocardiogram Clinical Information: Thirty-two hear old male, rule out pericardial effusion. Description: This is a fair to good quality examination. No pericardial effusion is seen. Thickening of the septum and left ventricular posterior wal is seen. Measured at 1.1 cm. The wall motion of the left ventricle appears to be globally reduces in a mild fashion. The aortic root is of normal size and the aortic valve opening is normal. The LA chamber is not dilated measuring 3.3 cm. The LV chamber is mildly dilated measuring 6.0 cm. The mitral valve structures open and close normally, and there are no abnormalities suggestive of mitral stenosis or mitral valve prolapse. The EPSS is increased mildly, greater than 1 cm. Conclusion:

1. LV concentric hypertophy, LV chamber dilation, and global reduction and LV ejection fraction, probably mild – moderate ejection fraction estimated at 40-50%.

2. No pericardial effusion identified.

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John Doe

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Sample Hospital Operative Report

Patient Name: John Doe Account #: 123445562 Unit#: 4543231 D/C Date: 8/10/01 Dictating Physician: Ima Doctor Date of Procedure: 8/09/01 Surgeon: Ima Surgeon, M.D. Preop Diagnosis:

1. POST PARTUM WITH UNDESIRED FERTILITY 2. CLASS C, TYPE I DIABETES

Postop Diagnosis:

1. POST PARTUM WITH UNDESIRED FERTILITY 2. CLASS C, TYPE I DIABETES

Procedure: 1. BILATERAL TUBAL LIGATION USING POMEROY TECHNIQUE THROUGH A

SUBUMBILICAL MINI-LAPEROTOMY ANESTHESIA: EPIDURAL FROM DELIVERY WHICH IS REACTIVATED, SUPPLEMENTED WITH 50cc OF50:50 MIXTURE OF MARCAINE 5% AND LIDOCAINE 2% WITH EPINEPHRINE

Specimens: Right and left fallopian tube segments. Finding: Bilaterally normal fallopian tubes, normal involuted uterus. Adnexal structures could not be otherwise clearly evaluated. EBL minimal. Complications, none. Preop Accu-Chek was 130.

Indications: This is a married Caucasian female, Gravida IV, para 1-0-2-1, with an EDC of 10/4/00, who underwent and amniocentesis to confirm fetal lung maturity secondary to unstable class C, type I diabetes mellitus. After fetal lung maturity was confirmed with the presence of PG, the patient was induced for labor and spontaneously delivered a 6lbs-2oz male, with apgars of 8 and 9. There were no complications to the delivery and a normal infant. The patient expressed prior interest in permanent sterilization for fear that her diabetes will progress and she recommits to this decision. The patient received preoperative counseling, which included the risks of failure at 4:1000 and the fact this procedure is done to be permanent. With full understanding of these risks the patient accepts the risks and understands the options, and she agrees to surgery.

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Patient Name: John Doe Account #: 123445562 Unit#: 4543231 D/C Date: 8/10/01

Procedure: The patient was taken to the operating room after epidural was enhanced to adequate analgesia. The abdomen was prepped with Dupraprep. A red rubber catheter was inserted through the vagina for continuous drainage into a collection unit. At this time the patient was draped with sterile drapes, sub umbilical area was injected with Marcaine approximately 10cc. Transverse incision was made within the folds of the subumbilical area. The subcutaneous tissue was dissected free and the fascia was identified, grasped and brought into the field where it was then entered transversely with a scalpel and then extended with Mayo scissors. Preperitoneal space was then carefully entered. Lidocaine/Marcaine mixture was poured inside. The opening was then rotated and patient positioned in order to visualize the fallopian tube. The fallopian tube was brought out into the field, where it was grasped and evaluated from the fimbriated end to the distal end. Attempt was made to ligate a portion of the tube, but it was then recognized that the fallopian tube itself was very close to that of the vasculature and therefore after careful identification a proper area of the fallopian tube was identified and adequate knuckle was created, and this was doubly tied using 0 Chromic plain and an intervening section was excised and tubal ostia was cauterized. On the patients right side this was more easily identified, the fallopian tube was identified and brought into the field and grasped and evaluated from the corneal and to the fimbriated end and a knuckle was created, and in a similar fashion this was ligated with two 0 plain catgut suture with intervening section being excised with Metzenbaum scissors and the tubal ostia being cauterized. Lidocaine/Marcaine mixture was poured over the peritoneum of the fallopian tube on both sides prior to the ligature. Additional Marcaine/Lidocaine mixture was poured inside the abdomen over the uterus and in the pelvis for postop analgesia. The fascia was closed using 0 Vicryl on a UR6 suture and the skin was closed using subcuticular closure with 3-0 Monocryl. The patient tolerated the procedure well without any complications and was taken to the recovery room awake, alert, clear urine, all counts confirmed as correct. Steri-strips were applied to the abdomen.

Electronically Signed by: Ima Doctor M.D.

D: 09/08/01 T: 09/08/01

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1507 W. Parkside Ln. Phoenix, AZ 85027 (877) 445-9293 (Phone) (817) 251-5424 (Fax)

TEST CHART COVER SHEET

CIOX CHART ID

(For purpose of assessment name folder ‘Assessment_YourLastName’

SITE ID

43314

1507 W. PARKSIDE LN

PHOENIX, AZ 85027

PROVIDER NAME

DOE, JOHN

PROJECT

TEST PROJECT