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 items to be included in the chart note is presented on right called Level-2 (Item). The Chief Complaint here includes a few common visit reasons at the top followed by an alphabetical listing of items.
The items list under Chief Complaint can be oriented any way you like. To add an item to the note, click in the box next to the item. When a box is clicked, additional items appear on the bottom or on the right for inclusion in your chart note.
Now let us go ahead and enter the Chief Complaint for a patient. The patient was referred from school due to an asthma attack and cough. To enter the Chief Complaint for the above scenario:
1. Click on Chief Complaint listed under SUBJECTIVE on the left side on the chart. A list of items will appear on the right, the item list here includes a few common visit reasons at the top followed by an alphabetical listing of visit reasons.
2. You can enter other details by selecting the required heading and choosing the corresponding items in the same manner as described above.
3. 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.
4. 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.
5. Click the Close button to close the charting screen and go back to the Clinical Desktop page and move on to the next patient.