Creating, signing, and updating patient charts

Starting a new patient chart

To start a new charting entry for a patient, visit their profile and then click on Charting > Chart entries. 

Click on New entry and fill the form with:

• The chart date;
• An optional name for the chart entry;
• The template you want to use as a starting point for this entry;
• The visibility of the entry;
• Check that the consent has been obtained from the patient.
• For multi-practitioners clinic, you can also allow your colleagues to add to this chart entry.

A quick note on the entry visibility: If you opted to make the entry Visible to patient, you can still hide individual chart items within the chart entry so they won't be visible to the patient. For the patient to be able to see the entry, the following criteria need to be met:

• The chart entry needs to be signed
• The patient needs to log in to their account from the unique URL for your clinic. You can find more information in the setting a subdomain guide.
  
  

A quick note on allowing your colleagues to add to the chart entry: If you opted to allow your colleagues to add to the chart entry, they will be able to add new chart items to the chart entry if they are also connected to the patient. However, they will not be able to modify any chart items not added by them, and conversely, you will not be able to modify any chart items that they've added.

On the chart entry page, click on Add a chart item to add a chart item to the chart entry.

Select the chart item you want to add and its visibility and click on Submit:

This will add the chart item to the chart entry where you will be able to fill it out:

Signing the patient chart

When you start a new chart entry, it will be in draft mode. The entry will not be visible to your patient even if you set its visibility to "Visible to patient".

When you have added and completed all the chart items to your chart entry, you can Sign it. Signing a chart entry have the following effects:

• It will delete all the chart items in the chart entry that have not been completed;
• It will prevent you from making any modifications to the chart entry;
• You can still revert the chart back to draft mode if the clinic has specified a reversal deadline. Learn more about chart settings and adding a reversal deadline here.

To sign the chart entry, from the chart entry page, simply click on the Sign button:

This will prompt you for a confirmation. Once accepted, the chart entry will be marked as signed.

If the chart entry was signed and the reversal deadline has not passed, you can revert it back to draft mode by clicking on the Revert to draft link.

Adding addenda

Once a chart entry has been signed and can no longer be reverted to draft, you can add an addendum to it.

To add an addendum, scroll to the bottom of the chart entry and click on Add addendum. 

Fill out the form with your notes and choose the visibility of the addendum:

Please note that the addenda can only be edited or deleted within 5 minutes after adding it.