Note: There are basically two scenarios when we start charting:

  1. Charting for a patient with an Appointment
  2. Charting for a Walk in patient (without Appointment)

To chart for a walk in patient, go to Clinical Desktop from the main menu and click on the Patient tab.

Search for a patient using any criteria (Last Name, First Name, Insurance ID, SSN, Home Phone, MR# and DOB). If this is a new patient, you can easily add a new patient using the  button which will open up the Electronic Medical Record for that patient.

Choose Face Sheet from the EMR of the patient where you can add, review or modify the various elements of the patient’s information like:

  1. CLINICAL MEASURES
  2. SMOKING STATUS
  3. ASSESSMENT
  4. PLAN OF TREATMENT
  5. GOALS
  6. HEALTH CONCERNS
  7. REASON FOR REFERRAL
  8. COGNITIVE STATUS
  9. FUNCTIONAL STATUS
  10. ALLERGY
  11. MEDICATION
  12. FAMILY HISTORY
  13. HEALTH MAINTENANCE
  14. MEDICAL HISTORY
  15. PERSONAL NOTES
  16. SOCIAL HISTORY
  17. SURGERY/ PROCEDURES
  18. VACCINATIONS
  19. PROBLEMS LIST

To add to any category on this screen click the corresponding  button .

For example, if you click on  button in the Allergy area, a pop up appears.

Click in the Allergy box and enter the substance to which the patient is allergic or type No Known Drug Allergies. In Status box set the degree of the allergy. Enter the Last Reviewed Date and the Reaction Status. If you have any comments, enter it in the Comments box. If the Show as Red box is selected, the details that you enter here will be displayed in red color on the Face Sheet page. Click the Save button to update the information.

The information will be saved and displayed in the Face Sheet page.