Resource Center

FAQ

SOAP Notes

 

How do I write chart notes?
You need to start a new encounter to write the chart notes for the patient.

  • Go the "Patients" tab and select the patient
  • Click on "Open New Encounter" and choose the type of encounter you would like to start
  • Once the SOAP notes section, opens up, you can start writing the chart notes.

What is the difference between different types of chart notes?
There are three types of chart notes, viz., Quick, Brief & Comprehensive.

  • Quick Chart note can be used during phone consultation and in scenario where minimal charting is enough
  • Brief chart note captures all the sections of SOAP (including vitals & Dx codes) in a single page.
  • Comprehensive chart can be used in places where you need to maintain detailed documentation about the patient visit.

How do I use templates for chart notes?
ChARM EHR allows you to create templates for most commonly used items, which you may write in the chart notes. You can create templates for most commonly treated ailments, where you can create canned items for chief complaints, recommendations, etc. At the time of encounter, you can pick up them from the template to fill up the soap chart, rather than typing it each time.

Can I add custom health vitals to EHR Nurse Input section?
Yes. Custom health vitals can be added from “Settings -> Encounter Settings -> Custom Vitals”.

Does ChARM allow exporting complete medical history of a patient?
You can export all the encounter notes as a PDF from “Patient Dashboard -> Past Encounters” section. In addition, you can also export the medical records as HL7 CCD file.

I would like to generate a Referral Report for a patient visit. How to do that?
Go to “Settings -> Templates” section and create a “Reports” template. You can use the place holder strings to fetch the values from encounter chart note. There are a few referral templates under “ChARM Template Library”. You can import and change them as well. Once you have created the template, you can use it to generate a “Referral Report” for an encounter from “Patient Details -> Past Encounters” section.

Does ChARM allow generating CDC growth chart with reference percentiles?
Yes, you can generate CDC growth chart in ChARM. Go to “Patient Details->Health Vitals” section and click on the “Growth Chart” link.

Is it possible to do markings on medical images?
Yes, you can do markings on the medical images and store them as part of the chart note. This feature is available as part of comprehensive encounter. Go to “Physical Examination” section and use the “Add Image Annotation” feature.

I am consulting patients with chronic diseases. Most of the time, the chart is same as of previous visit with minor modifications. What shall I do?
You can use the “Repeat Previous Notes” feature in Encounter section. The repeat feature completely copies the previous visit notes to the new encounter and you can do modifications to that. In addition, we do have repeat option for individual section of chart notes, viz., Rx, Dx, etc.

I have wrongly created an encounter, how do I delete it?
You can delete the chart note till it gets signed. Go to “Home -> Review Chart” section to delete the unsigned chart.

Can a Nurse sign (finish) a Chart Note?
No. Nurse can start a chart note for some other physician. But, they cannot sign the chart note. Only the practice member on whose name chart note is created can sign the note.

Can a Nurse view/edit the unsigned Chart Note?
Yes. Nurse can view the unsigned chart notes from “Home -> Chart Notes” section. They can also edit the chart note, but only the sections they are authorized to work in.

Can one practice member access/modify/finish other practice member’s unfinished chart notes?
Yes. This can be done from “Home -> Review Charts” section. But, they can’t sign unless that chart is filed to that person for review.

Is there a way to delete signed or unsigned chart notes?
Yes, Practice member can delete charts but they should be unsigned.

How long shall I take to sign a SOAP note?
There is no time limit for signing the chart note. You can sign it anytime. Normally, it is done at the end of the day.

Can I upload file over 10 MB? Is there a limit on the file upload size?
No. You cannot upload a file of size over 10 MB. But, you can split the files and upload them.

I have a supervisor who wants to review the chart note before signing. Is this possible?
Yes. You can let any other practice member to review your chart note by filing the chart for them to review.

Can I start an encounter without having an appointment scheduled
Yes. You can start the encounter, even if prior appointment is not scheduled with the patient. You can directly go to Patient Dashboard, click on “Open New Encounter” to start the encounter.

How can I add more questions to the existing template?
You can edit the existing template to add more questions. Please follow the instructions given below:

  • Navigate to “Settings -> Templates” section
  • Click on Action icon available for the template and choose “Edit”
  • Drag and drop the components available on the left hand side of the screen to the location in the template, where you would like to add them.