The Charting screen comprises of two main sections. On the left are pre built content headings
(SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN etc). Under these headings, different Level-1 components are listed. When a Level-1 component is clicked, a customizable list of Level-2 (Items) to be included in the chart note is presented on the right.
The Vitals Item list can be oriented any way you like. To add an item to the chart note click in the checkbox beside it. When a box is clicked, additional items appear on the bottom or on the right for inclusion in your chart note.
1. Click on Vitals listed under OBJECTIVE on the left side on the chart.
2. A list of items will appear on the right, the list here includes commonly recorded vital items.
3. Click in the checkbox beside Blood Pressure, choosing this option will bring up additional Options below to describe the Blood Pressure. (You also have the option to place the cursor next to Blood Pressure, click and write your own description if required.)
4. Click in the Blood Pressure options checkbox since the Blood Pressure of this patient is normal. This will add the description “normal” automatically next to Blood Pressure.
Similarly enter other details like Height, Weight, Temp, Pulse etc by selecting the required item in the same manner as described above.
5. To make this chart available to the physician for examination, click in the Save as options box and choose Ready for Exam option then click the Save As button.
6. The Charting Saved Successfully message will be displayed, click the Close button. The chart will be saved and placed under the Ready for exam tab on the Clinical Desktop.
7. Click the close button to close the charting screen and go back to the Clinical Desktop page and move on to the next patient.