Patient Chart: Chart Notes

This page provides document on Chart Notes, the basic note documentation tool. See below for topics and step by step instructions on using this feature.

Healthland currently offers 2 options for documenting notes.

• Chart Notes: The tool that has been in place for use with Centriq provides a basic template driven, documentation tool, that features Smart Tags to import data elements into the note.
  
• Notes: A structured documentation tool that allows clinicians to complete and build documentation using pieces of data throughout the application. To turn on the new Notes feature, contact your Healthland Account Manager.

In Centriq v11.0, the Notes feature replaced Chart Notes as a documentation tool for clinicians. Some sites may elect to utilize Chart Notes instead of Notes initially.

About Chart Notes

The Chart Notes page displays existing clinical notes for the patient and allows you to document new notes related to the patient's visit. You can type a free-text note or you can select a note from a list of pre-determined commonly-used notes. The Chart Notes page is equipped with a spell check feature. When you are typing, unrecognized words are underlined in red to alert you to the misspelling. Right-click the underlined word to view a list of possible substitutions and click the desired substitute to replace the underlined word. The following topics are discussed on this page. Use the links to jump to the desired subject:

To view notes

To sort and filter the chart notes

Cosigning Chart Notes

To enter a note

To detach a note

To create a DRAFT note

To search in a note

To add an addendum to a chart note

To edit a note

To view the Change Log

To copy a note from a previous visit

Using Smart Templates

To create/edit smart templates

To view notes

The Chart Notes page defaults to an abbreviated list of the available notes displaying the Type, Charted Date/Time, and Entered By information. To view the full note, click the View Details button. The details of the note are displayed, as well as any addendums to the note. To view all notes, click Expand All. To return to the abbreviated view, click Hide All. To include erroneous notes in the display, check the Include Erroneous box.

To sort and filter the chart notes

Typically, the chart notes are displayed for the current visit with the most recent entry at the top (reverse chronological order). However, you can sort and filter the entries using the fields located at the top of the page: Filter and Sort.  Click the black expand button (double arrow) located to the right of the Filter bar to display additional filter options: View, Start Date, and End Date.

• To filter the notes by type, select the desired note type in the Filter field.

• To determine the sort order, select the desired option in the Sort field.

• Since the default view is for the currently selected visit, use the View field to select other options: Recent Visits, Date Range, or All Visits. If you select Date Range, use the Start Date and End Date fields to specify the time period to view.

To save your selected filter options, click Actions > Save Filter Settings. This allows you to use the filter settings as your default view whenever the Chart Notes page is accessed. Note: This feature is controlled in User Administration by the Hospital - Patient Chart - Save Filter Settings security item.

Cosigning Chart Notes

The Chart Notes page allows cosigning of entries for providers, similar to the cosigning of transcribed documents. Mid-level providers (MLPs) can create the chart note, select a Supervising Provider to route the note to, and have a Supervising Provider cosign the note.

• In the PWC, a Documentation Needing Cosign section displays assessments and chart notes that require a co-signature.
• In Dr. Signature, a Documentation Needing Cosign tab displays all Assessment and Chart Note items that require a co-signature. From this list, the provider can Sign, Reject, Edit, Reassign, and/or Print the note/assessment.
• A report, Documentation Cosign Report, is available on the General Reports page, that can be used to view the notes that have already been cosigned, as well as those that still need a co-signature.
• The Change Log contains the audit trail for the activities of cosigning Chart Notes. 
• Use the Maintenance > Specific Application  Setup settings for Clinic > Auto Sign Parameters for Documentation and Hospital > Cosign Parameters for Documentation to define preferences.

Additional Information regarding Cosigning functionality:

• A user cannot edit the note/assessment from the PWC if he/she is not the creator of the item.

• A user can re-assign a note/assessment from the PWC only if he/she is the creator or cosigner of the item.

• A user can sign/reject the note/assessment from the PWC only if he/she is the cosigner of the item.

To enter a note

1. Click Add Chart Note. The Add Chart Note page is displayed.

2. The Charted Date/Time fields default to the current date and time. If necessary, use the calendar and clock icons to modify this information so it is accurate.

3. (Optional) In the Select Template field, begin typing text for the template you are looking for. Templates matching the typed text are displayed in two categories: Chart Note Templates and Smart Templates. Select the desired template. The template is displayed in the large text box. If you wish to add to the note or type a note without using a template, click in the text box and begin typing your note (go to step 5). (See Using Smart Templates for more information on creating and using Smart Templates.)

4. In the Note Type field, use the drop-down list to select the appropriate type of note. This is displayed on the Chart Notes page. (To set the selected note type as the default for this field when you access this page, check the Set note type as default box.)

5. The Notes field is used to create the complete note. Make edits using the following methods:

   • Click in the document and type additions or remove unwanted text.

   • Change formatting using the font, size, and text and paragraph formatting tools.

   • Print document using the Printer button.

   • Toggle the document to Full Screen Mode using the computer button.

   • Add caret (^) symbols where you would like cursor jumps. A cursor jump is used to navigate quickly to certain areas in the Chart Note when the clinician is entering the patient note. When entering the note, the cursor jump is activated by pressing the <F2> key.  Typically, the caret (^) is entered after a question or a section of the template where the clinician will be typing patient-specific information. For example, "What is the patient's pain level? ^". When the clinician is entering the note, they can press the <F2> key to jump directly to these carets (^) in the template allowing easy data entry.

   • Select patient data elements to be added to your template using the black buttons at the top of the page:

   • 1. The filter in the gray section defaults to None. If you would like to filter the data elements that will be displayed, check either Last or Range From.

        • If you select Last, make the appropriate selection in the quantity and time unit to identify the range of information, i.e. Last 1 hour, Last 3 days, Last 4 chartings. This means that the data that will be displayed will be from the selected period.

        • If you select Range From, use the calendar to select the beginning date. Data will be displayed using this selection as a beginning date and the current date as the end date.

     2. Use one of the following methods for selecting data:

        • Click the main black button to select the entire set of data in that category: Demographics, Allergies, Home Medications, Visit, Ordered Medications, and Vitals. For example, clicking the Demographics button adds the Patient Name, DOB, and Age to the template as a set called Demographics.

        • Or, you can point to the Demographics, Visit, or Vitals buttons to see a drop-down list and select a single element from the set, i.e., Demographics > Age, which is added to the template as Demographics.Age.

     3. Repeat steps a and b for additional elements you would like to add.

6. At this point, you have 3 options:

• Click Sign. The note is marked as complete and is displayed on the Chart Notes page.

• Click Discard. The note is removed and does not appear on the Chart Notes page.  

• Click Save as Draft. The note only appears on the Chart Notes and PWC/WC pages for the user who created it. Other users will not see the note until it is completed and signed using the Sign button. [To edit and sign a draft note, click the Edit button located next to your draft document, make changes and click Sign.]

7. Repeat steps 1-6 to enter additional notes.

To detach a note

Detaching a note opens it in a separate window to allow the clinician to review other areas of the chart as they write the note. Click Detach Note to open the note creation window in a new window. This window can be minimized, moved, and re-sized so that the user can review other areas of the chart. When minimized notes are open, a red notebook icon is displayed in the green footer bar. Click the icon to maximize the detached Chart Note window.

• If the main window times out and is redirected to the login screen while a chart note is minimized, the chart note window will display a message that the main session has timed out and the detached/minimized note will be closed in x (# set by the facility) seconds. (Setting made in Maintenance > General > Detached Chart Note Alert Message Time.) 
• If the selected patient is changed in the main window from the selected patient in the detached/minimized chart note, the minimized note will display a confirmation message with the patient name to ensure that the note is saved for the correct patient. 
• If you select to switch to a different Centriq application while a chart note is detached/minimized, a message is displayed with Save Draft, Discard Note, Continue Working options. 

To create a DRAFT note

Creating a draft note allows you to start your note and save it to be signed later. To create a draft note, follow the instructions detailed in To enter a note and click the Save as Draft button. The Draft note appears on the Chart Notes page as a DRAFT (but is unavailable for viewing) and as an alert on the PWC/WC pages. To complete, add to, and/or sign the note, click the Edit button located next to the document. When finished editing, click Sign - the Chart Note will then be viewable on the Chart Notes page for all users.

To search in a note

To search the text of a note, from the expanded Note Details section, click in the note field, type the text you are looking for and press <Ctrl> + <F> key. Matches to the typed text are highlighted.

To add an addendum to a chart note

From the list of chart notes, you can add an addendum to an existing note.

1. Click the Add Addendum Chart Notes button (green + button) next to the note you wish to add an addendum. The Add Addendum page is displayed. (Note: To view the original note and details, scroll down below the Addendum text box.)
2. In the Reason field, use the drop-down list to select the reason you are adding an addendum.
3. Then, in the Addendum text area, type and format the addendum text.
4. Click Save.

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To edit a note

1. From the Notes page, click the Edit button (triangle) next to the note that you would like to edit. The Edit Chart Note page is displayed.

2. In the Reason field, use the drop-down list to select the appropriate reason.

3. In the Notes field, edit the content of the note and use the formatting tools and/or the Smart Template (Smart Tags) data elements (black buttons), if desired. Or, to mark a note as erroneous, click Mark Erroneous. Using the Mark Erroneous option removes the note from the list. To see erroneous notes in the list, check the Include Erroneous box.

4. Click Save. You are returned to the Chart Notes page. Or, to go back to the Chart Notes page without saving, click Back. To view the history of the note (original value and new value), including edits and addendums, go to the Change Log.  

To view the Change Log

The Change Log displays the history of the note including the creation, edits, and addendums, along with date/time, user name, type of note, and action performed. To access the Change Log, click the View Chart Notes Change Log button (clipboard icon located to the right of the note). This displays the different logged actions for each note. To view details for each action, click the Show Details (magnifying glass) button. To view details for all actions, check the Show All Details box.

Click Back to return to the Chart Notes page.

To copy a note from a previous visit

Chart Notes can be copied from previous visits to the current visit.

1. Use the options in To filter entries to display previous chart notes.

2. Click the Show Details button (magnifying glass) to display the note and details.

3. Click the Copy to Current Visit button.  The Add Chart Note text editor view is displayed with the original note content displayed. Make edits as appropriate.

4. Click Save to save the note to the current visit.

Using Smart Templates

Smart templates are pre-defined templates for entering chart notes that also include specific patient information/data elements such as demographic, allergies, home medications, visit, ordered medications, and vital sign information that auto-populate the note. Once Smart Templates have been created, you can select them from Select Template field when adding a chart note.

To create/edit smart templates

Templates are created from the Chart Notes page. Go to Main > Chart Notes. The Chart Notes page is displayed. To begin creating a template, click Create Template. The Create Smart Templates page is displayed.

1. In the Template Name field, enter the name of the template you are building, i.e. Doctor Bedside Visit, Dressing Change, Patient Education, Discharge Instructions, etc. Or, if you are editing a smart template, begin typing the name of the template to locate and select it.

2. In the Notes text box, create/edit the template for the note.

   • Type the text that you would like to appear in the note. Use the formatting tools to change the way your text looks. To enlarge the text box to full screen, click the Toggle Full Screen Mode button,   .
     

   • Add caret (^) symbols where you would like cursor jumps (<Shift + 6>). A cursor jump is used to navigate quickly to certain areas in the Chart Note when the clinician is entering the patient note. When entering the note, the cursor jump is activated by pressing the <F2> key.  Typically, the caret (^) is entered after a question or a section of the template where the clinician will be typing patient-specific information. For example, "What is the patient's pain level? ^". When the clinician is entering the note, they can press the <F2> key to jump directly to these carets (^) in the template allowing easy data entry.”
     

   • Select patient data elements to be added to your template using the black buttons:

   • 1. The filter in the gray section defaults to None. If you would like to filter the data elements that will be displayed, check either Last or Range From.

        • If you select Last, make the appropriate selection in the quantity and time unit to identify the range of information, i.e. Last 1 hour, Last 3 days, Last 4 chartings. This means that the data that will be displayed will be from the selected period.

        • If you select Range From, use the calendar to select the beginning date. Data will be displayed using this selection as a beginning date and the current date as the end date.
          

     2. Use one of the following methods for selecting data:

        • Click the main black button to select the entire set of data in that category: Demographics, Allergies, Home Medications, Visit, Ordered Medications, Vitals, and Assessment and Plan. For example, clicking the Demographics button adds the Patient Name, DOB, and Age to the template as a set called Demographics.

        • Or, you can point to the Demographics, Visit, or Vitals buttons to see a drop-down list and select a single element from the set, i.e., Demographics > Age, which is added to the template as Demographics.Age.

1. 1. 3. Repeat steps a and b for additional elements you would like to add.

TIP: You can also click and drag the data set OR the individual data item into the template where you would like it to appear.

3. When finished creating and formatting the smart template, click Save.

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