Note: There are basically two scenarios when we start charting:
- Charting for a patient with an Appointment
- 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:
- CLINICAL MEASURES
- SMOKING STATUS
- PLAN OF TREATMENT
- HEALTH CONCERNS
- REASON FOR REFERRAL
- COGNITIVE STATUS
- FUNCTIONAL STATUS
- FAMILY HISTORY
- HEALTH MAINTENANCE
- MEDICAL HISTORY
- PERSONAL NOTES
- SOCIAL HISTORY
- SURGERY/ PROCEDURES
- PROBLEMS LIST
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.