Creating and Working with Chart Notes

Chart notes let you capture all the key details from a patient encounter, including symptoms, observations, assessments, and treatment plans. Solid charting keeps the team informed, supports quality care, and ensures your records stay compliant and organized. This section walks you through creating, updating, and managing notes step by step. It becomes straightforward once you get going!

Quick Tip: To start charting, open the Charting module. You need a calendar showing today or past dates with appointments, because notes always tie to a booked patient encounter. Providers usually see and edit only their own notes unless they receive extra access to a case file.

Create and Update Chart Note

To work with chart notes, open the Charting module. You need a calendar view showing current or past dates with scheduled appointments, because every chart note links directly to a booked appointment.

The system saves your changes automatically as you type, so there is no Save button needed. This lets you focus on documenting without worrying about losing progress.

You have two easy ways to begin: build the note section by section or apply a template to get a head start.

1. Select the appointment on the calendar.
2. Click New chart note.
3. Choose how to start:
   • Select a section, or
   • Switch to the Templates tab and pick a template.

Tip: Templates save time for routine encounters. After applying one, you can still add, remove, or rearrange sections to suit the visit.

4. The system creates a new draft note with your chosen section(s). It automatically sets the encounter date to match the appointment.
5. Add more sections by clicking Add section in the bottom-left corner.
6. With multiple sections in place, hover between any two to insert a new one exactly where needed.
7. Some sections include extra customization options, such as tables for vitals or ICD code lookups.
8. To adjust the encounter date, click Options > Change encounter date in the bottom-right, select the new date, and click Save.

Quick Access to Your Drafts
When no appointment is selected in the Charting module, the system lists all chart notes authored by the signed-in provider by default. Each note shows its date, the case file it belongs to, the provider name, and status. Notes appear in descending order, with the most recent ones at the top. This makes it easy to quickly find and complete any drafts that still need signing.

Rearrange and Insert Sections in a Chart Note

To rearrange sections: Use the Move up and Move down arrows in section toolbar to shift it higher or lower in the note.

To insert a section between existing ones: Hover between two sections. The Add section option appears. Click it and select the component you want to add.

Update a Draft Chart Note

Drafts stay editable until you lock them, giving you plenty of time to refine details or add information later. You can open and modify a draft from two places: directly in the Charting module or from within the related case file.

1. Open the draft you want to edit.
2. Make your changes as need and the system saved changes along the way.

Delete Chart Note

You can delete a chart note only while it is in Draft status. Once locked, the delete option disappears.

1. Open the draft chart note.
2. In the bottom-right, click Options > Delete chart note.
3. Type DELETE (all capitals) in the confirmation field.
4. Click Delete.

Warning: Deletion is permanent. Deleted notes cannot be recovered. Double-check before confirming.

Lock a Chart Note

Locking a chart note signs it off and makes it read-only. This prevents future changes and supports compliance and record integrity.

Important: Only the author of a chart note can lock it. The system prevents anyone else from doing so.

1. Open a draft chart note.
2. Click Sign in the bottom-left.
3. In the Sign and lock window, type or draw your signature, or use the pre-saved one from your profile.
4. Click Sign and lock.

The system locks the note and switches to read-only view.

Tip: Add your signature to your user profile in advance. It will auto-fill and save time during signing.

Add Amendment

Mistakes happen, even after locking. Amendments let you correct or add info without altering the original note, each one is signed and timestamped for transparency.

1. Open a locked chart note.
2. Hover over the section that needs correction. The Add amendment note option appears.
3. Click Add amendment note and enter your text.
4. Click Sign to finalize.

Note: Signed amendments are permanent. You cannot edit or delete them. Use them only for important corrections.

Duplicate a Chart Note

For ongoing clients, duplicating a previous note saves a ton of time. It copies the structure and content into a new draft for quick tweaks.

1. Open a locked chart note.
2. Scroll to the bottom and click Make a copy in the bottom-right.

The system creates a fresh draft copy, ready for edits. Perfect for follow-ups!