When the patient arrives for the consultation, you can measure their health vitals viz., Height, Weight, etc. and record it as part of the chart note. To record the health vitals, select the patient and open up a new encounter. Go to the 'Nurse Input' tab and select the 'Vitals' tab to to record the health vitals.
Here you will be able to enter the Weight, Height, BMI, Temperature, BP, and Pulse details of the patient. And the Nurse can also enter any special notes on the Nurse Notes section.
Next to the 'Vitals' tab is the 'Flowsheet' tab where you can fill-in the flowsheet for the current consultation. Select the name of the flowsheet from the combo-box on your right side and fill in the values.
When you created the appointment, you would have shared any pre-appointment questionnaires with the patient to get the details on his past health condition. These questionnaires are accessible from the 'Questionnaires' tab. Select the questionnaire name on the left hand side to view the filled-in questionnaire on the right side.
There are four different types of Charting available, viz., Quick, Brief, Comprehensive and SOAP template. Depending on the details to be recorded, select an appropriate type of charting when you start the encouter from the patient dashboard.
Once you open up the chart note, you will see different sections within to record consult notes, adding Dx codes, Rx, supplements, Vaccines, Lab Orders, etc. Fill in the details in the relevant sections to complete the chart note. You can either add the details instantly or from pre-defined templates that you had created earlier. Only the sections that are filled up appear in the final summary.
For instance to add the dianosis code, click on 'Add Dx'. The following dialog opens up. Type in a few words in the 'Diagnosis' field to search for the Dx code and add them to the chart.
Adding Supplements from Fullscript Database
Add the supplements to the chart by searching the Fullscript database using 'Add Sx > Fullscript' option
Search for the supplement from the Fullscript database
Click on 'Prescribe' link and add the intake details and add it to the chart
Adding Supplements from Fullscript Categories
Click on 'Load my Categories from Fullscript' option
Fullscript categories are loaded from the user's Fullscript account. Select a category to view all the products linked to that category. Choose the products and containers as required from the list. Fill the intake details and add the product to the chart.
Transmit Fullscript Orders Electronically
To send the prescribed supplements to Fullscript electronically, click on 'Transmit > Fullscript' option
The following dialog opens up. Select the supplements that you would like to send electronically to Fullscript. If you wish to provide discounts to the patients, use the 'Patient Discount' option from the 'Fullscript Discount Details' section.
There are two levels of discounts. The "Clinic Level Discount" is provided by Fullscript for your clinic will be applied to all your patients. On top of this discount, "Patient Level Discount" can be given to specific patients. Discount given to patients are persisted against the patient and will appear again for subsequent trasmissions. (Note that Clinic level discounts cannot be modified). Click on 'Send' button.
Note: Only the supplements that are added from Fullscripts database can be transmitted electronically
Once it is sent electronically, the supplement status changes to 'Transmitted Electronically'.
To send the prescribed medications to the pharmacy electronically, click on 'Transmit > eRx' option
The following dialog opens up to sign the prescription. Select the medications that you would like to e-prescribe and click on 'Sign & ePrescribe' button. Note that only the medications that are signed can be e-prescribed.
Search for a pharmacy or select the pharmacy from the preferred pharmacy list. Select the pharmacy and click on 'Send' to send the e-Rx.
Once it is sent electronically, the medication status changes to 'eRx Sent'. Note that eRx can also be done from the 'Chart Notes' section from the patient dashboard.
Note 1: ChARM supports electronic prescription of controlled substances (EPCS) by following the same steps described above. When prescribing CS drugs, providers need to additionally authenticate the prescription order through a 'hard token' two-factor authentication.
To know about how to subscribe for EPCS and start using it, refer the URL https://www.charmhealth.com/ehr/epcs.html
Note 2: Faxing Rx orders to pharmacy involves the same steps described above.
When you are finished with the consultation, you can enter the codes for the procedures you performed from the 'Procedure Codes' section. Select a 'Fee Schedule' and search the procedure codes in the 'Description' field. The pre-defned charges for the procedure codes will get populated and tagged with the chart note you had created. This will be helpful, when you want to generate insurance claims.
You can set up a reminder for the Vaccination when it is due. For setting up the reminder, select the patient and go to the patient dashboard. Click on 'Vaccines' tab from the left hand side menu. Then, select 'Patient Preferences' from the "More Options" (...) icon.
You will be prompted to add the Reminder and VFC Eligibility. You can set up the reminder and click Save.
Once you finish charting, you can file the encounter for review with another physician. To do this, click on "More Options" (...) icon and select the 'File For Review' option.
Select the physician to whom the chart should be filed for review. Click on 'Submit' and the review request will be sent to the selcted physician.
Once the chart is signed, you cannnot edit the chart to add more details. In this case, you can add an Addendum to the signed chart note. To add the addendum, go to the 'Chart Notes' section and filter the signed charts using the 'Chart Status' option.
Select the Encounter that you want to add the Addendum. Click on 'Addendum' to enter the additional notes that you would like to enter against the chart note.
You can print the chart notes, lab orders, etc that are part of the encounter. From the 'Chart Notes' section, select a chart note and click on the 'Print' button. From the menu, you can choose to print Chart Notes, Lab Order, Image Order and Patient Summary.
You can add quick notes to the patient's profile. For instance, if you are making a telephonic call to your patient, you can jot down the important notes about the call here. To add the quick note, select the patient and go to the patient dashboard. Click on 'Quick Notes' tab to the left and click '+ Add Note' option.
When you are prompted with the following dialog, enter the notes and save it.