THE CHART ICONS
Once you have entered into the "Document Visit" from the Schedule, this is what a Chart Note will look like. Let's review the icons.
Expand all Areas
Add Template
Add Area to Note
Save
Insurance & Total Visits
Sign Off
Diagnosis & Precautions
Total Billed Time
POC Expiration & Next Progress Due Dates
CHARTING BASICS
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 VISIT TEMPLATE
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!)
To load a template, click/tap on the "Template Icon" from the Chart Note.
Select the appropriate Template Category (organized by discipline)
And then select the Template for Your Visit Type.
CHARTING BASICS
There are three ways to create Clinical Content for a Chart Note:
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Use default choice
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Select from Option List
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Free text
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Clinicient uses a color scheme approach. Text in "orange" is a default selection or carry forward text from a prior visit. If left in "orange" or not selected, it will not be included in the signed report.
1. Use Default Choice
In the screenshot, the default choice for "Patient Self Report" is "good response to treatment. By checking the box to the left of "Patient Self Report", this option will be selected and the text color will change from orange to black indicating that this is now a part of the note. This is demonstrated by "Purpose of Today's Visit".
2. Select from Options
Many fields also have options that you can choose from which will appear below the field with a dropdown arrow. You have the option of selecting one or more of these alternate responses with just a click/tap of each choice.
3. Free Text
Free text is always an option and you can choose to enter text to replace a default choice/option list or in places where free text is required (such as blood pressure)
4. Required Items
Required items are marked with a small * next to the item and must be completed in order to sign off on a chart note.
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.
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.
