CHARTING BASICS FOR ALL TEAM MEMBERS
CHART F4 TAB OVERVIEW
An overview of the Chart F4 Screen with critical areas explained.
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Monthly Calendar. Month and Year you are viewing is at the top. Day you are viewed is highlighted in DARK BLUE. On the image above, the calendar is selected for 8/17/2019.
Appointments. This can be toggled to view appointments by day for a patient or to view an entire patient's record by switching to the"Client Tab". There is also an "Unsigned" Tab where any visits that are not signed will be grouped.
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Case Box. The Case Box is the name of the case assigned and always begin with discipline (PT, OT , SLP) and typically date of referral will follow, i.e., a case referred for PT in March 2019 will have a Case Name of PT 032019. Hovering over the box provides critical case information including diagnosis, plan of care and # of visits until a Progress Report is needed. A BLUE Case Box means that case has no issues; a RED case box means that a critical item is needed or about to be needed (i.e., the box will turn RED two visits before a supervisory visit is due.
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This area is called the Topic Editor and houses all clinical content, organized by Area and Categories within each area. The content for each Template that is used for documentation is housed within the Topic Editor and you can add additional content by expanding the sections to view additional choices.
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Charting Area. We will discuss adding content and how to chart in the next sections.
CHARTING BASIC STEPS
For EVERY visit, there are certain steps that must be followed to successfully chart, bill and sign off on a visit.
STEP 1
Schedule & Arrive the Patient [Go here if you need help]
STEP 2
Load Chart Template
STEP 3
Complete Documentation / Chart Note / Procedures
STEP 4
Sign Off
STEP 5
Attach Paperwork [Go here if you need help]
ADD TEMPLATE (REQUIRED)
Every visit type has a template associated 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!) Templates are organized by discipline and also Specialty Templates.
To load a template, click/tap on the "Template Icon" above the Chart Area and scroll to the discipline or template area you would like to use and select. A Confirmation Message will appear and then click "OK".
BASIC CHARTING
Clinicient uses a color coding system as well as a documentation carry forward feature to make documentation easier for the user.
Highlighted Text is the default choice from the Chart Template.
Red Text is a carry forward from a prior note's documentation.
Areas highlighted in yellow are required content and must be completed before a note is signed.
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Charting Options
There are three options to enter clinical content:
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Click once to save the default text. This will turn the text from highlight or red to black.
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Right click to see a list of default choices and make your selection from one or more of these choices.
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Free text to replace any existing content.
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 on the Area which you would like to add content. Areas are in Black Boxes with white text.
By clicking on the Area, you will be taken to the Corresponding Topic Panel Area.
Click on the + Symbol to expand and add a "check" to each field you would like to add. You can remove fields by simply "unchecking" your selection.
In this example, the chart visit will have PT Codes Therapeutic Exercise, Therapeutic Activity, Manual Therapy and Gait Training added, but not Neuromuscular Re-Education.
SIGNING OFF
After completing all required charting for your patient visit, the last step is to sign off. You will have an opportunity at time of sign off to ensure that your visit is being billed correctly and to adjust the time in/time out to actual if it is different than what was on the schedule.
Begin by clicking the "Sign" Icon to the right of the Case Box
Time Colors:
Green: Billed Time = Schedule
Red: Billed Time > Schedule
Black: Billed Time < Schedule
You can correct any errors by adjusting either Time or Procedures
Enter password and select "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.