This article explains the steps to initiate charting for walk-in patients as well as for patients with appointments.

Click on ‘Clinical Desktop’ on the main menu. This opens the Clinical Desktop screen which comprises of two sections: the Tabs section, and the Pending Charts section.

The tabs section comprises of six tabs as follows:-

Appointment:- Displays the list of patients with appointments for the current/given date.

Patient:- To Search for patients.

Reminder:- Displays the Reminders.

Ready for Exam:- Displays the list of patients with charts that are ready for examination.

For Review:- Displays the list of charts that have been assigned to be reviewed.

Message: This takes you to the Message facility where you can compose messages or view the Inbox and To-Do list.

The Pending Charts section will list the names of all the patients whose charts are open and pending (charts saved as pending).

Charting for a patient with Appointment

We can schedule an appointment in two ways- Appointment through Scheduler and online appointment scheduling through patient portal. All scheduled appointments are reflected on the clinical desktop Appointment tab; see Image 1.

Image 1

    1. When the Clinical Desktop screen opens up, all appointments of the current day with CONFIRMED and CHECKED IN status will be displayed (Missed appointments are excluded).
    2. The appointment list displays the details relating to the appointment like TimePatient(name), Reason (for visit), StatusExam Room and RP (Rendering Provider), Case Name, etc.
    3. To filter appointments by Status, select a status from the Status filter (CHECKED IN, CHECKED OUT, etc.). Select ALL from the status drop-down to show appointments irrespective of their statuses.
    4. To view the appointments for a particular Legal Entity or Provider, select the Legal Entity and the Provider from the respective boxes.
    5. Use the Previous and Next buttons to look for appointments preceding or following the current date.
    6. Click on the name of the patient from the list, the Electronic Medical Record screen will appear as shown in Image 3.

Charting for Walk-in Patients (Without Appointments)

Image 2

    1. From the Clinical Desktop click the Patient tab to open the Patient Search screen; see Image 2.
    2. Search for a patient using any of the search criteria (Last Name, First Name, Insurance ID, SSN, Home Phone, MR#, and DOB). To add a new patient, click on button seen on the top right (highlighted in Image 2). To select a patient using their name, type the first three letters of the name, a list of all the patients with the given name will be displayed; see Image 2. For example to search for a patient named TEST FRANK, type TEST in the Last Name box. The list of patients with their last name starting with TEST will be listed below. If you type Smith in the First Name box, a list of all patients having first name Smith will be displayed.
    3. Click on the name of the patient from the list, the Electronic Medical Record screen will appear as shown in Image 3.

Image 3

The EMR Screen

Image 3 is the EMR screen. On top of the page is the charting selection area from where you can select the type of Charting Sheet required. The header will have the basic info like Last visit date, future date, Insurance name, Active reminders. A tick mark beside the TeleMed icon on the top right hand side indicates portal access enabled for the patient. A warning icon  is displayed if portal access not made available to the patient.

PracticeSuite easily accommodates multiple complaints, multiple symptoms, and multiple disease chart notes. All the encounter Sheets available for the selected Provider will be displayed in the Encounter Sheet list. To begin charting, you have two options:

Option 1: Encounter Sheets

Choose an Encounter Sheet from the Encounter Sheet List and click the button and start charting; see Image 4.

Image 4

Option 2: Canned Sheets

PracticeSuite offers the users the ability to save common visit type chart notes as Canned Sheets or create customizable canned sheets, which makes charting quicker. Simply click on a respective encounter 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 button to start charting (the name of this button will change according to the type of Sheet selected). To know more on how to create Canned sheets, click here.

The Charting Screen

Charting Page Components

The Charting screen comprises two main sections, on the left are content headings that can be customized(E.g. ENCOUNTER SHEET, SUBJECTIVE, OBJECTIVE, ASSESSMENT PLAN, OTHERS ). Under these headings, different Level-1 (component)s are listed.

When a Level-1 (component) is clicked, a customizable list of items to be included in the chart note is presented on the 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.

You may use the to search.

Note: With PracticeSuite, you may type, handwrite, dictate, point and click or let your transcriptionist do the work. Any combination works fine.

Saving a Chart

1. The Chart can be saved in four different statuses:

Chart Save Option Icon Description
COMPLETE To save a chart which is completed
FOR_REVIEW
PENDING To save an incomplete chart; pending charts can be completed later
READY_FOR_EXAM Charts filled up by patients/ MA to be made available to the physician for examination
VOID To delete a chart

2. Intake forms, Allergies, Current Medications, Vital signs, etc. can be filled by patients through Kiosk or else by MA’s and can make this chart available to the physician for examination, click in the Save as drop-down and choose then click the Save As button. 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.

3. Click the Close button to close the charting screen and go back to the Clinical Desktop page and move on to the next patient.