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Charting Basics for All Team Members
Every patient, every visit, must include the following:
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Schedule and Arrive Patient (See Schedule)
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Load Chart Template
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Complete Documentation
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Code Procedures/Billing
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Sign Off
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Add Attachments (Signature Log, Intake Paperwork, etc.)
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Charting Basics
Charting Basics (Tx Visit)
BASIC NAVIGATION
On the left side of your screen will be the Icon. Click to expand/collapse access to the Client Information. At the top, are the following icons which provide Case Information:
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ICON
CONTENT
Diagnosis and any Precautions/Contraindications,. Box appears "Red" if there are precautions attached to the record and is blue if there are no precautions or contraindications established for the patient.
Authorizations. Will include total # of visits in POC and date Plan of Care expires. Shield Icon will turn red when total # of authorized visits has been reached or exceeded.
Billed Time Compared to Scheduled Time
The Icons on the right assist with navigation and adding content to the chart note.
Opens Uber-Conferencing to allow for audio with/without video conference call to a patient in a secure HIPPA compliance portal. Click here to learn more about this feature.
Areas are the sections of a note (i.e., Subjective, Objective, Assessment, Plan). This Icon expands all areas to view the entire note. Clicking the icon in each section expands just that one section.
Increases/decreases the font size for improved viewing
Accesses Chart Templates to Add a Template to the Note
This used to Add Area to Chart. It will most often be used to add an area such as Functional Assessment Tools.
Show Past Fields - a great shortcut to see content that was previously added to notes.
Saves the Note
Sign Off
ADD VISIT TEMPLATE
Every visit type has an associated Template which includes the Medicare required content as well as default content based on legacy charting. Templates ensure uniformity of information and that essential content is always included (and makes your documentation easier!) To load a Template, click/tap on the Template Icon and then select the appropriate template category and visit type.
And then select the Template for Your Visit Type.
After loading the template, click Expand All Areas to view the contents and begin charting.
CHARTING BASICS
There are three ways to create Clinical Content for a Chart Note:
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Use default choice which is highlighted in blue.
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Select from Option List which can be accessed from the ...
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Free text which can overwrite any content and can be done in any section/any line item.
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Note that not all items are required for every note. If an item is not applicable on a visit, you can leave the item highlighted and it will :fall off" the signed note.
Charting Options:
In the screenshot, the default choice for "Patient Is seen for "Skilled therapy consistent with POC. It is not yet selected.
To choose this option, you can click the Check Box or simply click/tap on the text. This will change the content to "Black" which means that it will now be part of the signed note.
You can see a list of options by clicking on the ... and selecting on of these choices
Alternatively, you can choose to simply free type and add whatever content you wish. This may also be necessary for items which have no default choices such as Blood Pressure.
REQUIRED ITEMS
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Some items are required for documentation. If an item is required, it will be highlighted in yellow and the chart note cannot be signed unless completed.
ADDING CONTENT
The templates provide the basic structure that is usually sufficient for most documentation including history, objective measures and tools and commonly used procedures. The example below demonstrates how to add content to Procedures but the process is the same for any area.
Step 1. Click/tap the "ADD" button on the right of the screen (present in each area).
Step 2. The "ADD CLINICAL CONENT" Box will open to the Clinical Content specific to your area (for example, Clicking "ADD" under Procedures will open up the "Procedures" Section. Select the desired procedure/content and click apply to add to your Note. "Recent" which show you a list of recently used content by area.
SIGNING OFF
After completing all required charting for your patient visit, the last step is to sign off. Begin by selecting the pen and paper icon located at the top right corner of the screen. This will take you to the Sign Off Documentation Box which has three separate tabs: Time Reconciliation, Faxing and Sign Off
Time Reconciliation Screen
You can correct any errors by adjusting either Time or Procedures
Faxing Tab (SKIP)
Sign Off
Unable to Sign Off Message
If there are errors or documentation that is required, the system will prevent Sign Off and will provide you with details of what is needed to complete sign off. Once corrected, you will be able to sign off on the visit.
UN-SIGN / MAKE CORRECTIONS
Once a note is signed, it is locked for protection and cannot be modified by anyone except for the signor. If you need to make a correction to a note, you can un-sign by loading the note, In the upper right , there will be a "Lock Icon" which you can select, enter the reason for changing the note and your electronic password and make changes as necessary.
