Patient Chart

Patient Chart

Patient Profile (Demographics)

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    Create New Patient Profile

    1. Click Patients 
    2. Click New Patient (see picture)
    3. Enter the patient’s demographic information (required fields marked with an asterisk)
    4. Click Save

    Open / Edit Existing Patient Profile

    1. Click Patients
    2. Enter the patient’s name, date-of-birth or account number> click Search Patient (see reference) > double-click the correct patient
    3. Click Patient Profile (see picture)
      1. Or select an appointment > click Patient Info
    4. Edit view or edit the patient’s information in each of the tabs (General, Insurance, Guarantor, Emergency Contact, Care Team)
    5. Click Save

    Take Patient Picture

    1. Setup a compatible webcam (see CloudEMR – Hardware & Software Requirements)
    2. Click Patients
    3. Enter the patient’s name, date-of-birth or account number > click Search Patient (see reference) > double-click the correct patient
    4. Click the picture in the upper left-hand corner (see picture)
    5. Click Capture
    6. Click Save and Close

    Patient Summary (Chart)

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      Open Patient Summary

      1. Click Patients
      2. Enter the patient’s name, date-of-birth or account number > click Search Patient (see reference) > double-click the correct patient
        1. Or right-click an appointment > click Open Chart (see reference)
        2. Or select an appointment > click Patient Chart (see reference)

      “Add to” Patient Summary

      1. Open a Patient Summary (see picture)
      2. Click + next to the correct summary section (e.g. Encounter, Diagnosis, CPT, etc.) and fill out the new entry
        1. Or click the summary section title (e.g. Encounter, Diagnosis, CPT, etc.)
          1.  Click + and fill out the new entry
        2.  Or click Timeline
          1. Click the correct timeline tab (e.g. Encounter, Diagnosis, CPT, etc.) > click + and fill out the new entry

      “Delete from” Patient Summary

      1. Open a Patient Summary (see picture)
      2. Click the entry to be deleted > click the Delete button
        1. Or click the summary section title (e.g. Encounter, Diagnosis, CPT, etc.)
          1.  Select the entry to be deleted > click the Delete button
        2.  Or click Timeline
          1. Click the correct timeline tab (e.g. Encounter, Diagnosis, CPT, etc.) > select the entry to be deleted > click the Delete button

      Print Forms

      1. Open a Patient Summary
      2. Click the summary section (e.g. Encounter, Diagnosis, CPT, etc.) that corresponds to the desired form
        1. Or click Timeline
          1. Click the correct timeline tab (e.g. Encounter, Diagnosis, CPT, etc.)
      4. Find Form > select the desired form (see configuration)
      5. If necessary, Fill the form > click the Printer button
      6. Click Print in the browsers print window

      Add “PostNote”

      1. Open a Patient Summary
      2. Find the PostNote drop-down > select the desired option (see configuration) > enter a custom note
        1. Press Enter

      Delete “PostNote”

      1. Open a Patient Summary
      2. Find the PostNote section > click – next to the entry to be deleted

      Print Patient Summary

      1. Open a Patient Summary
      2. Click the Printer button
      3. Click Print in the browsers print window

      Send Message

      1. Open a Patient Summary
      2. Click the Message button
        1. Or select a pre-configured quick message from the drop-down
      3.  Compose a message
      4. Click Send

      Patient Notes (Documents)

      View Patient Notes

      1. Open a Patient Summary
      2. Click Patient Notes
        1. Or right-click an appointment > click Patient Notes (see reference)

      Upload Patient Notes

      1. Open a Patient Summary 
      2. Click Upload
      3. Select the correct file to upload > select a new name from the drop-down (see reference)
        1. Or enter a new file name 
      4. Click Upload

      Reference Guide

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        Patient Summary

        • Patients: opens patient lookup (see reference)
        • Patient Tab: displays patients last name, first name and account number 
        • Patient Photo: displays the patients photo
        • Last, First, Provider, etc: displays patient’s demographics

        • Patient Profile: opens patient information window
        • Patient Notes: opens patient notes
        • Print: prints current patient’s summary
        • Post-Note: adds post-notes to current patient’s summary
        • Upload: uploads files to current patient’s chart

        • Summary: opens current patient’s summary
        • Timeline: opens current patient’s timeline 
        • Diagnosis, CPT, Authorization, etc: summary sections (see configuration) 
        • Main: displays frequently used (see configuration) templates
        • Order Tabs: displays frequently used (see configuration) orders (i.e. Labs, eRx)

        Patient Timeline

        • Summary: opens current patient’s summary 
        • Timeline: opens current patient’s timeline  
        • Allergies, Authorization, CPT, etc: timeline tabs (see configuration) 

        Patient Timeline Toolbar

        • Add: creates a new entry
        • Edit: edits the selected entry
        • Save: saves current entries, selections and changes
        • Cancel: cancels current selections
        • Delete: deletes the selected entry
        • Search: searches the current tab’s entries
        • Print: prints the current tab’s data

        Patient Summary Toolbar

        • Refresh: refreshes the patient summary with the most up-to-date data
        • Audit Chart: lists what changes users have made to that patient’s chart
        • History: lists the the most recent changes to that patient’s chart
        • Clear History: deletes that chart’s history
        • Recently Closed: lists recently closed charts
        • Recently Deleted: restores recently deleted charts

        Patient Notes Toolbar*

        • Refresh: refreshes patient notes with the most up-to-date data
        • Exit: closes the patient notes window
        • Save: saves changes made to the current patient note
          • Save, On Hold: creates a task with the current note as an attachment to remind the user it is unfinished before saving changes made to the patient note
          • Download Chart Notes: opens the “Select File(s)” window to download patient notes
          • Rename Document: renames the current patient note
          • Export Document: downloads the current patient note
          • Merge Document: opens the “Merge Documents” window to combine multiple chart notes
          • Extract Pages from PDF: splits PDF files into multiple patient notes
          • Delete Document: deletes the current note
          • Comment: opens the “Document Notes” window to comment on the current patient note
          • Export to Sites: exports the current patient note to other facilities
          • Share with: exports the current patient note to other solutions (e.g. Patient Portal, Care Team Portal)
        • Cancel: cancel changes made to the current note
        • Send to Chart: opens the “Patient Lookup” window to select to which chart to route, link or copy the current patient note
          • Inbox: moves the current patient note to the “Inbox”
          • My Documents: moves the current patient note to the selected destination in “My Documents”
          • Shared: moves the current patient note to “Shared”
        • Print: prints the current patient note
        • Fax: faxes the current patient note (see eFax)
        • Patient (Email): emails the current patient note to the patient
        • Fill: starts filling the current patient note’s macros
        • New Message: opens the “Message” window with the current patient in the “Relates To” field
          • Drop-down: select from pre-configured quick messages
        • Patient Info: opens the “Patient Information” window
          •  Drop-down: select other sections of the patient summary (e.g. Encounters, Diagnosis, CPT, etc.) to open
        • Dictate: records audio in the current patient note for transcription
        • Sign: prompts for a signature via a compatible ePad device 
        • Signature: prompts for a password to authorize a pre-configured digital signature 
        • Order & Forms: opens orders (e.g. eLab Orders, eRx, etc.) and forms
        • Stamp: stamps pre-configured images (e.g. Signatures, Logos, etc. ) into the current patient note 
        • Delete: deletes the current patient note
        • Open as PDF: opens the current patient note in a local PDF viewer (e.g. Adobe Acrobat, Google Chrome, etc.)

        Message Window

        • To: enter to whom the message will be sent
        • Relates To: enter to which patient the message relates
        • Subject: enter the subject of the message
        • Attachments: selects which patient notes to attach to the message
        • cc Journal: adds this message to the patient’s Journal
        • Forms: selects which forms to attach to the message

        Advanced Configuration

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          Configure Forms Options

          1. Click Settings > System Configurations > expand Summary > click Templates

          • Template: selects the template to include
          • Section: selects where to include the template
          • FillOption: chooses how to fill the template when opened from the selected section (see picture)

          Configure Diagnosis Options

          1. Click Settings > System Configurations > expand Patient > expand ICD9 > click Diagnosis

          • PatientDiagnosis Diagnosis: enter the diagnosis name

          Configure CPT Options

          1. Click Settings > System Configurations > expand Patient > expand CPT > click Procedure

          • PatientCPT Procedure: enter the procedure name

          Configure Document Folders

          1. Click Settings > System Configurations > expand PatientChart > expand Document > click Folders

          • Folder Name: enter the folder name
          • SortSeq: enter the sequence with which to sort the folders
          • Default: selects the folder in which to save unsorted documents

          Configure Scanned Document Sorting

          1. Click Settings > System Configurations > expand PatientChart > expand Document > click Preset

          • Document Name: enter the name of the document to be sorted
          • Folder: selects the folder in which to save the sorted documents

          Configure Template Sorting

          1. Click Settings > System Configurations > expand PatientChart > expand Document > click Grouping

          • Template Name: enter the key pattern, word or phrase to sort the templates against 
          • Folder: selects the folder in which to save the sorted templates

          Notes:

          The system will search for user specified keys and move templates matching that key to the specified folder. The key must be set between two asterisks (e.g. *key-word*).

          • Key Pattern: some set of letters or numbers
          • Key Word: some word 
          • Key Phrase: some set of words

          Configure Chart Summary Sections

          1. Click Settings > System Configurations > expand Customization > expand Summary > click Sections

          • Section Name: selects the section in which to include in the patient summary
          • Order: enter the sequence with which to sort the folders

          Configure Summary Template Panel

          1. Click Settings > System Configurations > expand PatientChart > expand Summary> click Templates

          • Template: selects the template to include in the patient summary
          • Section: selects the section in which to include the template
          • FillOption: selects the default behavior of the template (see picture)

          Configure Timeline Tabs

          1. Click Settings > System Configurations > expand PatientChart > expand Timeline > click Tabs

          • Name: enter the name of the patient timeline tab
          • SortSeq: enter the sequence with which to sort the folders

          Configure PostNote Options

          1. Click Settings > System Configurations > expand PatientChart > expand PostNote > click Listing

          • Name: enter the name of the PostNote
          • Content: enter the options for each PostNote section