Pre-Implementation Questionnaire
Facility Name:
Welcome to WoundCare
MD
My name is Courtney Reay and I am your implementation specialist for Woundcare MD, the
product of choice for your center's electronic health record (EHR). My primary responsibility is
to ensure a successful seamless transition from your current documentation process to
Woundcare MD.
To accomplish this process, the implementation team will need to perform a needs analysis,
which involves gathering pertinent information to understand key workflows and organizational
priorities.
We will also require additional information to establish the database.
This exercise will help us make your EHR implementation more efficient. We look forward to
optimizing your documentation and outcomes tracking efforts through use of WoundCareMD.
An integral part of a successful implementation is a thorough analysis of the end users skill level,
readiness and willingness to undertake this change. We recommend beginning the process of
identifying and building an engaged team to facilitate this process.
We will call to arrange and interactive conference call to review the information submitted. I
look forward to meeting you.
Thank you for your prompt attention and interest.
Courtney Reay
WoundcareMD Project Manager
EHR Implementation Manager
Email: [email protected]
Phone: 813-932-1510 Ext.1016
Fax: 813-932-1503
Emergency Contact: 813-505-0272
6919 N. Dale Mabry Hwy, Suite 250
Tampa, FL 33614
Attestations
The information in the fields below, attest that the named individual agrees with the content of
this form.
Name:
Position/Title:
Email:
Phone Number:
Date Completed: / /Pre-Implementation Questionnaire
Section I: Program Description & Operations for Outpatient Wound Programs
Please tell us more about your program so that we can determine appropriate WoundCareMD settings and on-site training for your specific users:
I.I. Facility Information
Name:* Address:*
Phone Number(s): Fax Number(s):
Company Email:
o
N/A
Note:* Filled details will show on all printed documentation in the WoundCareMD system. (i.e. FL.Wound Care & Hyperbaric Center)
I.II. Contact Information
Facility Contact for Training
Name: E-Mail:
Phone Number: Fax Number:
Program Director
Name: E-Mail:
Phone Number: Fax Number:
Clinical Manager
Name: E-Mail:
Phone Number: Fax Number:
Position/Title:**
Name: E-Mail:
Phone Number: Fax Number:
Position/Title:**
Name: E-Mail:
Phone Number: Fax Number:
Pre-Implementation Questionnaire
Section I: Program Description & Operations for Outpatient Wound Programs
I.III. Facility Description & Clinical Support
1. What is the current method for patient charting?
2. Is the hospital or department accredited by any agency? o Yes o No 2a. If Yes, Name of accrediting agency?
3. How long has the program been open? Date:
4. What is your operational program based on?
o
PT-Based
o
NP
o
Physician-Basedo
WCON-Based
5. What type of facility is this program in?o
Hospital Outpatient
o
LTAC
o
Long Term Careo
Home Health
6. How many active patients do you currently have? Patients7. Will you plan to add your active patients in the system prior to going live?
o
Yes
o
No
7a. If No, Will you be providing the details to WoundCareMD to input the information?
o
Yes
o
No
8. How many end users will be using the WoundCareMD system?
Receptionist Authorizations Hyperbaric Technicians Nurses Physicians Directors Coders Medical Records I.T Department
9. Estimate the daily census/patient volume at your location?
Monday : Tuesday : Wednesday : Thursday : Friday : Saturday :
10. What are the hours of service for this program ?
o
Weekdays:
o
Weekends:
Pre-Implementation Questionnaire
Section I: Program Description & Operations for Outpatient Wound Programs
I.IV. Network & Computing Components
1. Is your plan to have a designated data entry person or point of
care?
o
Designated Person
o
Care Provider
2. How many treatment rooms in the program? TX Rooms 3. Do you plan to have a computer/laptop in each room?
o
Yes
o
No
If no, where? 4. Describe the current set-up of the equipment?o
Stationed
o
Mobile
o
Other:
5. What type of hardware will you be using with WoundCareMD?
o
Desktop PC:
o
Tablets :
o
Motion C5
o
Other:
6. Will you be leasing the equipment from WoundCareMD?
o
Yes
o
No
7. Does the department have wireless internet service?o
Yes
o
No
8. Do you plan to print hard copies of records or maintain a paperless chart?o
Yes
o
No
9. What is your time preference to be displayed in WCMD?
o
12 Hour
o
24 Hour (Military Time)
10. If you have HBOT, how many chambers do you have? # of Chambers10a. Is there computer access in this area.
o
N/A
o
Yes
o
No
11. Do you have a relationship with a Management Company in your woundand/or HBO departments?
11.a If yes, Please provide name and contact details
o
Yes
o
No
I.T Department Contact
Name: E-Mail:
Phone Number: Fax Number:
Please provide the details below to the best of knowledge about the computing environment: Hardware:
Server: Operating System:
Pre-Implementation Questionnaire
Section II: On-Site Training Plans
II.I. "Go Live" Information
1. What is your anticipated Go-Live date?
2. What are the Conference/Training Room Amenities? 2a. Are there enough computers for each user.
o
Internet Access
o
Telephone
o
Computer
o
Projector
o
Yes
o
No
3. How many end users will need WCMD on-site training? ***
Receptionist Authorizations Hyperbaric Technicians Nurses Physicians Directors Other: ** Note: Read Only users and physicians will be trained via web-based education.
II.II. Comments
Please make additional comments regarding your facility, your staff, and your plans for implementation of the EHR. This will help WoundCareMD Program staff understand your unique circumstances so that we may provide better support to you in this effort. Feel free to include any specific questions or concerns you may have.
