Start Charting

Chart notes are a key and essential part of documenting patient progress and ensuring continuity of care. You may also have different charting requirements depending on billing insurance & claims to justify services provided.

In our system we give you a variety of options for charting client appointments.

In this Article

Charting: From the Dashboard View

With this approach you can chart on appointments from:

  • Today
  • Charts in review (supervisors/supervisees)
  • Uncharted Appoointments
  • Incomplete Charts

Steps:

  • After initially logging in, or by clicking home Home (left menu)
  • Find the left section(s) discussed above
  • If not expanded, click on the section to view all appointments listed
  • Click on the appointment

Example:


  • On the appointment pop up, click the button:


Charting: From the Calendar View

  • After initially logging in, or by clicking calendar_today Calendar (left menu)
  • Click on the appointment
  • On the appointment pop up, click the button:


Charting: From the Today View

If you're in the today or autopilot view, you can chart on todays appointments (or use the date picker).

  • After initially logging in, or by clicking home Home (left menu)
  • Click the top left button


  • Click on the appointment, revealing the appointment details
  • On the appointment pop up, click the button:

Appointment Not Today?

Change the date just below Today's Schedule (top left) shown here:

  • Click on either the month or year up top to change quickly
  • Or use the grey arrows at the top left and right to switch months

Charting

When you start out charting, we humbly suggest completing this process from top to bottom to avoid mistakes or missing information until you're familiar with the layout and your needs

  • First select your chart entry style at the top
  • Use one of our pre-built templates (HIPAA & SOAP), or your own chart note template


Then define the specifics, including:

  • CPT Codes (price & quantity)
  • Service Modifiers
  • POS Code
  • Appointment start & end times
Note: We support the ability to change the CPT code local_atm cost directly from charting, highlighted below! You can manually change the amount if different from the default CPT code cost you normally charge.

  • Beneath that comes the actual chart note

Example of our HIPAA style template:

Click to see a larger version

Below that, the Notes section is where your remaining chart notes for the session go.

Within the editor, we support the following formatting:

  • Text sizes → from heading 1-6 and normal text
  • Formatting → bold, italic, underline, and small text
    • Additionally → bullet points, numbered bullet points, and paragraph indentations


Charting Behavior

When charting on a client, with the built in HIPAA & SOAP templates, the system "remembers" the last entered chart note and values. So if you typed out a HIPAA or SOAP note style template like above, the fields are remembered, leaving you to continue where you left off.

Here we will break down each charting templates, use the links below to jump to a specific one:

new_releases We've made some recent changes to the HIPAA charting template, please see our dedicated article about that by clicking here.

Simple (Narrative Note)

Here we load a simple editor alongside the diagnosis codes:

  • Add or update the Diagnosis Codes if needed

Within the notes editor, we support the following formatting:

  • Text sizes → from heading 1-6 and normal text
  • Formatting → bold, italic, underline, and small text
    • Additionally → bullet points, numbered bullet points, and paragraph indentations


  • Similar to the HIPAA template, you also have the option to copy the previous note
  • If one was previously entered, the button for this is under the Notes section
  • Click the button:



When locking the chart note, we automatically include in the chart note:

  • Client Name & Birthdate
  • Appointment Date and Start / End Times
  • CPT Code & POS Code
  • Diagnosis
  • The Notes
Click here for the remaining charting steps

SOAP Notes

A SOAP note is a standardized method for healthcare professionals to record patient chart notes. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan.

  • If you've already charted a SOAP note previously, all values are pulled forward from the previous SOAP note
  • Even if you've charted with another chart type since, changing the chart entry style back to SOAP note will pull up the last previously entered SOAP note if one exists


Expanded:

Click to see a larger version
Click here for the remaining charting steps

Chart Note Templates

  • When using chart note templates we load whichever template you select
  • Add or update the Diagnosis Codes if needed (above Notes)

Within the notes editor, we support the following formatting:

  • Text sizes → from heading 1-6 and normal text
  • Formatting → bold, italic, underline, and small text
  • Additionally → bullet points, numbered bullet points, and paragraph indentations


Example:

Click to see a larger version
Want to use a chart template in addition to using the standard HIPAA chart note template? Review our article here on the HIPAA note template feature.

Treatment Plan

  • Want to include a treatment plan? Toggle this to Yes to expand the treatment plan section
  • Enter or edit your client's treatment plan, and optionally set the next treatment plan due date
  • Setting a due date also shows up on your dashboard! Click here for more information
Note: For more information about treatment plans, please check our our article here.

Private Notes

Any notes entered here will only be visible to the provider (or records custodian) and will not be included by default in the clients chart when printed.

You can choose to include these with the printing chart note records feature

🎉 Congratulations, you've finished your chart note!

  • At the bottom right corner, click
  • This brings you to the chart review screen
  • Review your chart note for any issues or errors
  • If you have automatic payments when charting enabled, it will show up under the Payment section

For more information about automatic payments when charting click here.

After you've reviewed this screen, find the three buttons at the bottom right:

  • Click  to electronically sign & permanently lock the chart note
  • Click if you wish to return to this chart note later to edit and lock, but not yet
  • Click to be brought back to the chart note draft

After Locking:

Based on the client's insurance claim settings, a claim may also generated (but not submitted) after locking.

This setting can be found by:

  • Going to the client profile
  • Find the Primary Insurance section (near the bottom)
  • Within the section header click the button


edit_square Make a mistake or need to add more to a locked chart?

Please check out these other options after locking a chart note: 

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