How do I complete a chart note?

You can learn more about how components of the chart note relate to Meaningful Use here.

Encounter type
Every encounter note will automatically have an encounter type of Office visit selected, though you can adjust the type as needed. This is the basic categorization of what type of visit occurred, e.g. office visit, nurse only, or home visit.

Only Office visit, Home visit, Nursing Home visit, and Telemedicine visit will count toward Meaningful Use and clinical quality measures calculations.



Chief complaint and vitals
These fields can be completed by any user with an Edit Level of Nurse or higher.

Orders
Create and submit lab and image orders electronically directly from an encounter for a more holistic view of the patient visit. Orders that have been associated with a chart (either by ordering from the encounter or selecting an encounter note within the order) will display in the Orders section with the associated status (e.g. draft, submitted, received). If the order is saved as a draft, you can click on the draft to complete the ordering workflow.


Screenings/Interventions/Assessments

Screenings, assessments, and interventions are events which took place during the patient encounter, such as preventive screenings, referrals, or additional diagnostic tests. Learn more >>


Some items recorded here are shared with patients through their personal health record (PHR). See the complete list.

Observations
This section contains the
Functional status and Cognitive status fields. To record a functional or cognitive status, click Record next to the section header to open the search window. Enter at least 2 characters into the search field to begin returning results and continue typing to narrow down the search.Func_status_searchpng

Once the relevant status has been selected, the associated SNOMED-CT code will display and the Date field will default to the date of service on the encounter. If necessary, you may opt to change the date by clicking on the calendar icon. Information entered in the Observations sections is not shared with the patient through the patient portal.

Examples of functional statuses include:

SNOMED CT® 711561004 Has access to planned means of suicide
SNOMED CT® 397675006 Demonstrates knowledge of wound healing process
SNOMED CT® 397699006 Demonstrates knowledge of medication management
SNOMED CT® 225452001 Paranoid delusion
SNOMED CT® 225450009 Homicidal thoughts
SNOMED CT® 225448001 Has imaginary friend
SNOMED CT® 225036005 Distortion of memory
SNOMED CT® 224998004 Slow learner
SNOMED CT® 162200009 Temporary loss of memory
SNOMED CT® 165301001 Memory: important person not known

Examples of cognitive statuses include:

SNOMED CT® 711561004 Has access to planned means of suicide
SNOMED CT® 397675006 Demonstrates knowledge of wound healing process
SNOMED CT® 397699006 Demonstrates knowledge of medication management
SNOMED CT® 225452001 Paranoid delusion
SNOMED CT® 225450009 Homicidal thoughts
SNOMED CT® 225448001 Has imaginary friend
SNOMED CT® 225036005 Distortion of memory
SNOMED CT® 224998004 Slow learner
SNOMED CT® 162200009 Temporary loss of memory
SNOMED CT® 165301001 Memory: important person not known

Please note that these were previously free-text fields. Any information previously entered as free-text will be retained.

Quality of care
Quality of care data is used to record additional actions taken during the encounter. These items also feed into specific clinical quality measures (CQMs) and Meaningful Use measures. This information is not shared with the patient through PHR.

Care Plan
Simply record your care plans and instructions in the Care Plan section of the note, and the notes in that section will automatically be available to patients in their personal health records (PHR) once you sign the note. Learn more >>

Charting

  1. How do I search for patients in the EHR?
  2. How do I customize my patient chart view?
  3. How do I complete a chart note?
  4. How do I use rich text editing when charting my encounters?
  5. How do I add ICD-10 diagnoses to a patient chart?
  6. How do I add a medication?
  7. How do I use flowsheets?
  8. How can I preview previous encounters and results while completing an encounter?
  9. How do I print a patient's chart or certain sections of the patient's chart?
  10. How do I print a chart note?
  11. How do I add past medical history (PMH), allergies, medications and diagnoses to an encounter?
  12. How to record and print patient demographics and profile
  13. What information is available in a patient's Timeline?
  14. How do I use the growth charts?
  15. How do I merge duplicate charts?
  16. How do I print the care plan?
  17. How do I open an existing patient chart?
  18. Can vitals be added in Metric Units or US Customary Units?
  19. How do I add advanced directives?
  20. How do I add allergies?
  21. How can I edit my signed chart note?
  22. How do I add Family Health History?
  23. What is the difference between a SOAP and Simple note?
  24. What are the Character Limits when Charting?
  25. What are the limits of simultaneous editing?
  26. What are Screenings/Interventions/Assessments?
  27. Where can I learn more about the different components of an encounter?
  28. How do I delete or deactivate a patient?
  29. How do I edit information on the Patient Summary?
  30. How can I view Diagnosis comments?
  31. How do I search for inactive patients?
  32. What are Clinical Decision Support (CDS) advisories?
  33. How do I change the date in an encounter?
  34. How do I populate the list of Frequently prescribed medications?
  35. How do I view more information for medications?
  36. Why am I receiving the error "Unable to sign" when trying to sign a chart note?
  37. How do I delete an unsigned encounter?
  38. Who can sign a chart note?
  39. How do you change the 'Seen by' provider in the new encounter?
  40. How do I add a patient?
  41. What information is required to save a patient's chart?
  42. How do I create a patient record number?
  43. How do I edit an existing SOAP or Simple Note?
  44. How do I record "Unknown Family History?"
  45. How do I pull history from one patient visit to the next?
  46. How do I refresh a patient's chart?
  47. How do I start a new note/encounter in Practice Fusion?
  48. How do I export a patient record (clinical document)?
  49. What is the file size of a patient image?
  50. Can I move a Patient Record Number from one chart to another?
  51. How do I view or update a patient's appointment within their chart?
  52. How do I add a custom medication?
  53. How many charts can be open and how do I close them simultaneously?
  54. How do I assign a Care Team?
  55. How do I add vitals to flowsheets?
  56. How do I customize my template line settings?
  57. How do I set my patient list and Timeline default?
  58. How do I attach a document to an encounter?
  59. How do I create and update "My Dx List"?
  60. How do I add custom allergies?
  61. How do I participate in the Prolia® Safety Program?
  62. How do I document patient risk score?
  63. How do I document an implantable device?
  64. How do I document social history?
  65. How do I add goals to the patient Summary?

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