Outbound Information

This manual is designed to assist healthcare organizations wishing to receive HL7 transmission of transcribed medical records from Scribe systems. It is assumed that the user of this manual has a working knowledge of HL7 and TCP systems and their configuration.

In order to receive HL7 document transfer messages from Scribe, the organization may need the following information:

Please provide Scribe with the following information to complete the connection:

Scribe uses HL7 version 2.5 message formats to encode documents for transfer to healthcare organizations. Included in the message are the following segments:

Documents are sent as MDM – Medical Document Management messages – with event T02 – original document notification and content. In rare cases, documents that have errors and need to be corrected are sent with event T10.

A sample message format is included below and is provided as a separate text file for parsing/testing purposes.

TXA|1|OP^OperativeNote|TX|200410160927|12345^WELBY^MARCUS|200410160927|200410161711|200410271502|12345||SCRIBE|176931|||||AU||AV||||

OBX|1|TX|||HISTORY: Left kidney stone.~~CT ABDOMEN WITHOUT CONTRAST KIDNEY STONE PROTOCOL~Compared to a CT of 10/14/2003.~~TECHNIQUE: Five-millimeter spiral sections obtainedthrough the abdomen without IV or oral contrast.~~FINDINGS: Fibrotic changes, with honeycomb pattern,are seen in the lung bases. The liver, spleen, pancreas, gallbladder, and adrenal glands are unremarkable.~The right kidney is normal and there is no right hydronephrosis. There is moderate left pyeloureteralcaliectasis.~IMPRESSION: Consistent with moderately high-grade obstruction of the left kidney. Interstitialfibrosis with honeycomb pattern in the lung bases.~CT PELVIS WITHOUT CONTRAST KIDNEY STONEPROTOCOL~TECHNIQUE: Five-millimeter spiral sections obtained through the pelvis without IV or oralcontrast.~FINDINGS: The patient has a rather tortuous left ureter which is difficult to trace into the pelvis with accuracy.||||||P

1.	- Sending Application – this will always be “SCRIBE_HL7_OUT”

2.	- Sending Facility – this will always be “CHG_EQ”

3.	- Receiving Application – this will be unique to the client

4.	- Receiving Facility – this will be unique to the clinet.

5.	- Date of Message – this will be generated as the message is sent.

6.	- Message Type – this will either be “MDM^T02” or “MDM^T10”

7.	- Message Control ID – this will be a unique number generated as the message is snet

1.	– Patient Identified List - Scribe will provide the PatientID as the MRN (Medical Record Number) of the patient first from an ADT feed if available, second from the physician’s dictation if available, or a unique Scribe ID should the others not be available.

2.	– Patient Name – Scribe will provide patient surname and given name first from ADT feed, or second from physician’s dictation.

3.	– Date of Birth – Scribe will provide data of birth first from ADT feed, or second from physician’s dictation. Otherwise this will be blank.

1.	- Document Type – Scribe will provide document types based on the template type selected by the physician for their transcription. These document types can include:

Page 3 Last Updated January 7, 2005 Scribe Outbound HL7 Document Transfer Manual 2005

1.	o PH - Psychiatric history and physical examination

6.	- Document Content – all documents are sent as type TX

7.	- Activity Date/Time – this is the date of service dictated by the physician (if available).

8.	- Primary Activity Provider – this is the name of the dictating physician and includes the physician’s ID if provided as part of an ADT interface, otherwise it will include the physician’s Scribe UserID

9.	- Origination Date/Time – this is the date of the dictation by the physician.

10.	- Transcription Date/Time – this is the date the transcription is completed.

11.	- Edit Date/Time – this is the date/time that the document was approved by the physician.

12.	- Originator Code – is the same as the physician’s ID and is either what is provided as part of and ADT feed or the physician’s Scribe UserID.

13.	- Transcriptionist Code – in most cases this will be simply “Scribe”. If another transcription company is using the scribe platform to send documents, that transcription companies name will appear in this field.

14.	- Unique Document Number – this is the Scribe transcription file id and is unique.

15.	- Document Completion Status – this is always sent as “AU” as only authenticated and approved documents are sent.

16.	- Document Availability Status – this is always sent as “AV” as only documents that are available are sent.

1.	- Admit Date – if available from either ADT feed or dictation, the admit date will be provided.

2.	- Discharge Date – if available from either ADT feed or dictation, the discharge date will be provided.

1.	- Set ID – this is always “1” as there is only 1 observation set in each message

3.	- Observation Value – This is sent as a long string with the entire text of the document.

Scribe transfers documents via HL7 only when they have been approved by the physician on the Scribe platform.

If you require additional information please contact your Scribe account manager.