Online Charting
Simplify your charting process with customizable chart note templates. You can effortlessly generate and sign chart notes directly from a scheduled appointment, within a case file, or using the built-in charting app.
Chart Note Templates
Simplify charting with chart note templates. Build templates using tools that allow you to create any type of initial assessment or subsequent visit encounter note.
- Use these tools to build chart note templates that can gather information such as a patient’s medical history, laboratory reports, list of medications, results of physical examinations, special diagnostic tests, and consultations.
- Build your templates with the toolkit, which consists of 8 charting elements: chief complaint, vitals, notes box, body chart, spine chart, scale, checkbox lists, table, sketching notepad, and attachment.
- Speed up the creation of chart note templates by making a copy of an existing template and rebuilding it.
Charting After Treatment
We all know completing chart notes immediately after treatment would be ideal. The details are still fresh in your mind. Don’t allow anyone to slow you down; duplicate chart notes from the last visit and update where they apply.
- Duplicate chart notes from the previous day, make the required changes, then sign and lock.
- Pick a template to help complete initial assessments, reassessments, or discharge reports.
- Use tools to create a chart note on the fly.
Record Keeping Standard
Clearly documented and easy-to-read chart notes add value to your documentation. By signing off and locking your chart notes, you can effortlessly comply with your professional college regulations.
- Create and store chart notes in the case file on every patient encounter.
- Sign and lock chart notes once completed because medical records are legal documents and should never be altered.
- Add amendment notes when needed to correct locked chart notes. The system will date the revision and add the name of the person making the change.
- Online charting will make your chart notes legible so the patients and colleagues can easily read and understand them.
Share with Stakeholders
The payors, legal representatives, and governing bodies may request a copy of the chart notes on file. Download the listed chart notes in PDF.
- Filter chart notes by provider discipline and date range.
- Create and download the filtered list of chart notes in one PDF document.
- Securely share chart notes with colleagues and stakeholders using CaseRM.