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).
Charting for a Walk in patient
1. From the Clinical Desktop, click the Patient tab, the Patient Search will be displayed.
2. From this screen, you can search for a patient using any criteria (Last Name, Firslb_trit Name, Insurance ID, SSN, Home Phone, MR# and DOB). If this is a new patient, you can easily add a new patient using the add button.
To select a patient, type the first three letters of the name of the patient, a list of all the patients with the given name will be displayed.
For example to search for a patient named Thomas Dona, type Tho in Last Name box. The list of patients with their last name starting with Tho will be listed below. If you type Don in the First Name box, a list of all patients having first name Don will be displayed.
3. Click on the name of the patient from the list, this will take you to the EMR (Electronic Medical Record) page. The patient’s Face Sheet, where you can add, review or modify the various elements of the patient’s information like:-
ALLERGY , MEDICATIONS , FAMILY HISTORY
HEALTH MAINTENANCE , PROBLEMS LIST , PERSONAL NOTES
SOCIAL HISTORY , SURGERY/PROCEDURES , VACCINATION
4. To add to any category on this screen click the corresponding add button .
For example if you click on add button in the Allergy area, a pop up appears (as shown below)
a) Click in the Allergy box and enter the substance to which the patient is allergic or type No Known Drug Allergies.
b) From Status box set the degree of the allergy. (The fields marked with ê are required fields)
c) Enter the Last Reviewed Date and the Reaction Status.
d) If you have any comments, enter it in the Comments box.
e) 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.
f) Click the Save button to update the information.
The information will be saved and displayed in the Face Sheet page.
Opening a New Chart
On top of the page is the charting selection area from where you can select the type of Charting Sheet required.
1. PracticeSuite.com easily accommodates multiple complaint, multiple symptom and multiple disease chart notes. All the Consultation Sheets available for the selected Provider will be displayed in this list. From this list you have the option to:-
• Choose a Consultation Sheet from list and click the New Encounter Sheet button and start charting.
• Choose a Consultation Sheet from the list and then choose a Canned Sheet (if available) pertaining to that sheet and click the New cannedsheet chart button.
2. PracticeSuite.com offers the users the ability to save common visit type chart notes as Canned Sheets, which makes charting quicker. Simply click on a Consultation Sheet and all the Canned Sheets saved under it will be listed in the Canned Sheet list. Choose the required Canned sheet and click the New_cannedsheet_chart button (You have to build up the Canned Sheets). Refer to:- How do I create a Canned Sheet?
3. Click on this button to start charting. (The name of this button will change according to the type of Sheet selected.)
The charting page will be displayed as shown below.
4. Click on the various Level-1 (component)s on the left arranged under the different heading (For e.g. SUBJECTIVE, OBJECTIVE, ASSESSMENT PLAN ,OTHERS ).
When a Level-1 (component) on the left is clicked, a customizable list of items to be included in the chart note appears on the right.
5. To add an item to the note simply click in the open box to the left. Once an open box is clicked, additional items will appear in the bottom or on the right to include in the chart note.