What does the "Couldn’t include markable diagram" error message mean?

Limited Access

Markable diagrams are currently available for eReferral form types only and must be enabled by an OceanMD employee.

What is the problem?

Certain referral forms on the Ocean Provider Network may be configured to generate and include a markable diagram image as an attachment within the eRequest upon sending. This configuration is most common in diagnostic imaging pathways.

If you attempt to send an eRequest but are met with an error message stating "Couldn’t include markable diagram. Save your progress and try using a different browser to submit this eRequest", this means that Ocean was unable to generate the diagram image to include in the eRequest.

Since the diagram image is an important piece of information for the recipient of the eRequest, you are prevented from submitting the request without it.

What should I do?

To prevent the loss of your progress in filling out the referral form, we recommend using the 'Save for Later' functionality to save your referral form responses and then re-attempt the submission using a different web browser.

If the issue persists in a different web browser, please contact the OceanMD Support Team for assistance.


Can a Markable Diagram be adjusted after the eRequest has been sent?

Limited Access

Markable diagrams are currently available for eReferral form types only and must be enabled by an OceanMD employee.

Yes, a markable diagram can be adjusted after the eRequest has been sent. This can be done by following the steps below:

  • Locate and open the relevant eRequest.

    You can view the original diagram markings by clicking the purple eye icon on the attachment in the 'Messaging' area.

  • To adjust the diagram markings, click the pencil icon within the 'Referral Form Summary' area.
  • Adjust the markings by clicking/unclicking on the diagram, and then click 'OK'.
  • A new message will be added in the 'Messaging' area outlining the adjustments made to the diagram markings, as well as a new file attachment containing the updated markings.

    The new file attachment can be differentiated from the original file attachment by addition of the word "edited" in the filename, as well as an updated timestamp of when the new file was generated.

    The textual description of the markings will also be updated in the 'Referral Form Summary' area.

    The eRequest will automatically be flagged in the recipient's 'Needs Review' folder to inform them of the adjusted markings.


How do Markable Diagrams appear in my EMR?

Limited Access

Markable diagrams are currently available for eReferral form types only and must be enabled by an OceanMD employee.

Ocean supports the ability to include markable diagrams in eForms and include the diagram image as an attachment in a submitted eRequest.

When an eRequest is sent to or accepted by a Directory Listing that uses this functionality, the diagram image is considered to be an attachment within the eRequest and may be automatically imported to your integrated EMR.

Note: If your Ocean Site is not integrated with your EMR, the diagram image is automatically included in the manually downloadable eRequest PDF.

How does it appear in my EMR?

Sending an eRequest

PS Suite Med Access Accuro OSCAR Pro

If your 'Automatically Import Attachments to EMR' Cloud Connect setting is disabled, the diagram image will not be automatically imported into PS Suite.

  • If your 'Automatically Import Attachments to EMR' Cloud Connect setting is enabled, the diagram image will be included as part of the eRequest information summary PDF that is automatically added to the PS Suite patient chart upon sending.

Accepting an eRequest

PS Suite Med Access Accuro OSCAR Pro

PS Suite with Cloud Connect Integration

If your 'Automatically Import Attachments to EMR' Cloud Connect setting is disabled, the diagram image will not be automatically imported into PS Suite.

  • If your 'Automatically Import Attachments to EMR' Cloud Connect setting is enabled, the diagram image will be imported into PS Suite chart as a PDF attached to a Progress Note containing the name of the file.

PS Suite without Cloud Connect Integration

If your PS Suite EMR is not integrated using Cloud Connect, the diagram image will not be automatically imported into PS Suite.


Can I modify the eForm used during the eReferral/eConsult reviewal process?

  • Yes, the questions presented in the 'Review' panel during the eReferral/eConsult reviewal process are customizable.
  • The questions in this panel correspond to a specific Ocean eForm (named 'Referral Notes') in your Ocean site. By modifying this eForm, it modifies the questions presented during the reviewal process.

Warning: Advanced eForm Editing

The Referral Notes eForm should only be modified by Ocean users who are familiar with advanced eForm editing. We recommend creating a backup version of your Referral Notes eForm before modifying it.

How to Modify the Referral Notes eForm:

  • Locate the 'Referral Notes' eForm in your eForm library. This eForm has the reference value 'referralNotes', which is the eForm reference value that Ocean will use in the 'Review' panel of an eReferral.

    In other words, the eForm which has the 'referralNotes' reference value will be shown in the 'Review' panel.

  • Select the eForm, and press 'Edit' to launch the eForm editor.
  • Within the eForm editor, you can modify or add additional questions that should be displayed within the 'Review' panel during the reviewal process.
  • The preview panel on the right hand side shows how the note will appear in the 'Notes' panel of the eReferral once it has been reviewed and saved.
  • Use the 'Save Changes' button in the bottom right corner to save your eForm when you are done making changes.

Important eForm Item References

Each item in an eForm is assigned a specific item reference value. Item reference values are often used to implement conditional logic into eForms, however they are also sometimes used to push information from the eForm into a specific area or functionality within Ocean.

  • For the 'Referral Notes' eForm specifically, the item references 'protocol' and 'priority' can be used to push information into the respective 'Protocol' and 'Priority' columns in the eReferrals area.
  • Expand the image on the right to see where the 'priority' item reference value is stored for the highlighted eForm item. The 'protocol' value is not present in the default version of the Referral Notes eForm, but it can be manually added.
  • The text value shown on each of the response choices represents the text value that would be pushed into the respective column in the screenshot above. These can be modified in the 'Menu Choices' tab.
  • Note: We highly recommend using an eForm item type that allows for discrete response choices (e.g., a Menu) to simplify the process within the 'Review' panel of the eReferral. This also ensures that the values pushed into the 'Protocol' and 'Priority' columns are standardized across all reviewed eReferrals.


How to Manually Import a Sent eReferral into PSS

In the rare case that an Ocean eReferral Custom form, or the referral note summary, does not download into the patient's PSS chart after an eReferral is sent, users can re-trigger the download by following the steps outlined below.

  • Access the Ocean Patient Dashboard by selecting "View in Ocean" on the Ocean Toolbar in the patient chart.
  • Locate the sent eReferral that needs to be re-downloaded into the patient chart, and click it to open.
  • Once the referral opens, click the Action menu located in the top-right corner.
  • Select the "Import into EMR" option.

This action will trigger the entire referral form summary, as well as the Ocean eReferral tracking form, to download into the patient chart. Any internal PSS messages or Pending Tests/Consults, associated with the referral, will download as well.


What happens when an eReferral is sent with more than one Health Service Offering requested? (eReferral Splitting)

In some referral pathways, such as the Diagnostic Imaging pathway, it is common for a patient to be referred to a listing with more than one Health Service requested (for example a referral for a CT and an Ultrasound).

In these cases, rather than having the referrer complete two separate referral forms (one for the CT and one for the Ultrasound), the referral form at the recipient site can be designed to allow both exams to be requested on the same referral.

  • Here's an example of a referral form where the referring provider can select more than one exam.
  • Note: Selecting more than one exam will assign more than one Health Service Offering to the referral form. This will give the recipient the opportunity to "split" the referral into separate referrals - one for each offering assigned.

The Splitting Policy

  • As the referral recipient, you can configure your listing to automatically "split" referrals into multiple referrals that can be managed separately within your Ocean site. This setting is configured from the Admin Settings page by clicking on Directory Listings. From here, navigate to the Enablement tab, and locate the 'Automatically split requests with multiple services into separate requests' setting under the 'Request Policies' section.
  • If the Splitting Policy is enabled at the recipient site, the referral will automatically come into the New box as separate referrals. The sender will see the same thing occur in their sent folders.
  • If the Splitting Policy on a listing is turned off (left unchecked), the referral will come into the site as a single referral with multiple services assigned to it.
  • The recipient can review the referral first and choose to split it into multiple referrals (one for each service). This manual split can be done using the "Split" button displayed at the bottom of these referrals when opened.

The Relationship between Split Referrals

  • When referrals are split, a relationship is established between the original referral that was sent, called the "Source" referral, and each of individual referrals that were generated after the split. These individual referrals are commonly referred to as "Child" referrals. Both the Source Referral and each of the Child referrals can be found listed in the Related Referrals section, displayed at the bottom of each split referral.
The Source Referral
  • The Source Referral can be viewed if the referral sender or recipient would like to see a summary of the original referral that was submitted, and a list of each Child referral and their corresponding statuses.
  • The Source Referral can be accessed from the Action menu of each of the individual referrals.
  • Or it can be opened from the Related Referrals table, by clicking the "View Source Referral" link displayed on any of the individual Child referrals.
  • The Source Notes section on the Source Referral, can be used to add notes or information that is relevant to all of the related referrals.
  • Any notes added to this section will display on each of the Child referrals, separate from their Notes pane which captures notes specific to that individual referral.
  • Note: If there are no Source Notes added to the Source Referral, then this section will NOT display on the individual Child referrals.
The Child Referrals
  • When a Child referral is opened, any other Child referrals from the original split can be viewed, along with their status, in the Related Referrals section at the bottom of the referral view.
  • To navigate between these referrals, you can click on the name of the related referral, or click the "View Referral" link, in the right hand column of the Related Referrals table.
  • Note: After a referral is split, each of the child referrals will operate individually in Ocean, with its own appointments, status updates, email notifications, notes, and messages tied to it. 

The Referral Form Summary on Split Referrals

  • The Referral Form Summary is generated from the information filled out by the referring provider on the referral form. The Source Referral will display all of the information completed on the form, including sections that are applicable to each of the services selected.
  • In a standard referral split, that same Referral Form Summary will be displayed on each of the Child referrals that get generated. However, the referral form can also be designed at the recipient site to only display specific parts of the original Referral Form Summary on each of the child referrals. This is to help with the management, and triaging of each child referral. For example, when you view the Ultrasound child referral, you may only see the sections relevant to that service in the Referral Form Summary.
  • Note: Both the referral splitting, and the generation of these child referral form summaries, will depend on the design and configuration of the recipient's referral form and listing.

Deleting Source & Children Referrals

  • Source referrals cannot be deleted directly. Source referrals are automatically deleted when all their respective children referrals have been deleted first.

Creating Inbound Requests

If your Ocean Site receives referrals by phone or fax, you can convert these into Ocean eReferrals by creating a New Inbound Referral.

If your Ocean Site receives referrals by phone or fax, you can convert these into Ocean eReferrals by creating a New Inbound Referral by following the steps outlined below.

  • Log in to the Ocean Portal and navigate to the eReferrals & eConsults area.
  • Expand the "Actions" menu at the bottom left and select "New Inbound Referral".
  • Indicate the original source of the referral.
  • If there are multiple Directory Listings in your Ocean Site, you will be prompted to select which listing the referral was directed to.
  • Fill out the 'Patient Information' section.

    Patients can receive email notifications regarding the status of the referral if email consent was provided. The patient's email address can be added at the time of the creation of the inbound referral, or after the inbound eReferral has been created.

  • Enter the original 'Referral Received Date'.

    This is the date the referral was originally received at your clinic outside of Ocean (e.g., via fax or phone) and is used in wait time calculations. This date can typically be located on the physical paper fax copy (or in your clinic's digital fax software of choice, if applicable).

    Note: Referrals can be backdated up to a maximum of 10 years in the past.

  • Using the 'Service' dropdown menus, select the relevant Health Service Offering and referral form for the referral.
  • Fill out the fields in the Ocean referral form using the information from the original referral (e.g., the fax).
  • In the 'Referrer's Information' section, manually enter the referrer's information.

    Alternatively, use the 'Import...' button to auto-populate the information from the referrer's Directory Listing in the Ocean Healthmap (if available).

  • To import the referrer's information, type their name into the text box and choose their listing from the list of results.

    Note: If any information requires updating, update these fields in the 'Referrer's Information' pane of the eReferral and it will be saved for next time.

  • When all of the information for the referral has been entered, click the "Send Referral" button in the bottom right corner of the window.
  • If the patient's email address was included in the Patient Information section, you will be prompted to confirm that consent was given by the patient to send them email notifications regarding important referral status updates.
  • For safety reasons, you will be prompted to confirm the clinical information including the patient, the source site, and the referrer.
  • The eReferral will now appear in the "New" inbox in the eReferrals & eConsults area of your Ocean Portal.

    These inbound eReferrals can be managed in the same way as any other received Ocean eReferral, with the exception that no referral notifications will be sent to the referrer through Ocean.