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SOAP Notes

 

How do I write chart notes?
If you want to create an encounter without an appointment:

  1. Navigate to the Patient's 'Dashboard > Encounters' section.
  2. Click the '+ New Encounter' button. This opens the 'New Encounter' window.
  3. Choose the required 'Chart Type'
  4. Click on the 'Create' button.

In case of scheduled appointments, you can create an encounter using the following steps:

  1. Navigate to your appointment in the Calendar > List View Section.
  2. Click on the 'Encounter Start' link available on the right-hand side.
  3. Choose the required 'Chart Type'
  4. Click on the 'Create' button

What is the difference between different types of chart notes?
There are four types of chart notes:

  1. SOAP note stands for Subjective, Objective, Assessment, and Plan. It allows Providers to document consultations in a universal structure that is easy to interpret.
  2. During phone consultations and in scenarios where minimal charting is sufficient, you can use Quick Chart notes.
  3. Brief chart note captures all the sections of SOAP (including vitals & Dx codes) on a single page.
  4. Comprehensive charts allow you to maintain detailed documentation about the Patient visit.

How do I use templates for chart notes?
Charm supports a template-driven approach for creating Chart Notes. You can create various Templates that will help you speed up routine data entry during the Consultation.

For example, you can create Templates for SOAP consultation, Prescriptions, Diagnosis, Lab orders, Vaccination, Referral Reports, etc. Members with the necessary role privilege can create templates in the Settings > Templates section. The detailed steps to create templates are available in this link.

Can the nursing staff enter the health vitals of a patient without starting an encounter?
Yes, the nursing staff can enter the health vitals from the 'Patient Dashboard > itals' Section. The vitals data the staff enters is automatically pulled inside the chart note when the physician starts an encounter.

To enable this feature, go to 'Settings > Encounter > Preferences', and click 'Yes' for 'Copy the vitals recorded under Patient > Vitals section to chart note'.

Can I add custom health vitals to the EHR Nurse Input section?
You can add custom health vitals from the 'Settings > Encounter > Vitals > Custom Vitals' section.

Does Charm allow exporting the complete medical history of a Patient?
Yes, go to Patient Dashboard > Dashboard > Face sheet and export the Patient face sheet. It exports the Patient's complete medical history. You can also export Patient encounters individually or in bulk.

I would like to generate a Referral Report for a patient visit. How to do that?

  1. Go to the Settings > Templates section
  2. Click on the 'My Templates' option.
  3. Click on the '+ New Template' button and enter the name of the Template.
  4. Choose the Template type as 'Reports' and click on the 'Proceed' button.
  5. You can use placeholder strings to fetch the values from the chart note.

There are a few referral templates under the '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 the 'Patient Dashboard > Encounters > All' section.

Does Charm allow generating a CDC growth chart with reference percentiles?
Yes, ensure you have enabled the Growth Chart feature under Settings > Encounter > Vitals section. Then, you can generate a CDC growth chart using the steps below:

  1. Go to the 'Patient Dashboard > Vitals' section.
  2. Click on the 'More Options' icon (3 dots icon) present in the top right of the screen and choose 'Growth Chart'.

Alternatively, you can access the Growth Chart from the Encounter section.

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 SOAP or Comprehensive encounters.

  1. In SOAP Encounter - Go to 'Import Images' option at the top. Import the image and start annotating it.
  2. In Comprehensive Encounter - Go to 'Physical Examination' section and use the 'Add Image Annotation' feature to add markings.

I consult Patients with chronic diseases. Most of the time, the chart is the same as the previous visit with minor modifications. What shall I do?
You can use the 'Repeat' feature available in the Encounter section of SOAP and Comprehensive chart notes. It copies the entire data available on the previous chart note. You can modify them based on your requirement. Additionally, you can repeat individual Chart Note sections like Prescriptions, Diagnosis, Labs, etc., using the 'Past RX', 'Past Dx', and 'Past Labs' options available in each section.

Alternatively, you can subscribe to our Chart Note Recommendation feature to speed up filling Chart Notes by:

  • Suggesting appropriate ICD-10 diagnoses (Dx) codes from the notes section.
  • Recommending plans based on diagnoses combination from previous chart history of similar Patient profile.

I have wrongly created an encounter, how do I delete it?
For unsigned encounters, Members with the necessary role privilege can delete them using the following steps:

  1. Go to the 'Patient Dashboard > Encounters > Unsigned' section.
  2. Click on the 'Trash Bin' icon against the encounter. Alternatively, you can click on the 'Trash Bin' icon against the encounter in the 'Chart Notes' section.

Ensure that you enable the 'Unlock' option in the 'Settings > Encounters > Preferences' section for signed encounters. Then follow the steps below:

  1. Go to the 'Patient Dashboard > Encounters' section.
  2. Choose the signed encounter and click on the 'Unlock' button.
  3. Enter the 'Reason' and click on the 'Ok' button.
  4. The unlocked encounter gets listed under the Unsigned section. Clicking on the 'Trash Bin' icon deletes it permanently.

Similarly, you can perform the same steps in the Chart Notes section.

Can a Nurse sign (finish) a Chart Note?
No, the nurse can start a chart note on behalf of a physician. But, they cannot sign the chart note. Only the physician whose name is on the chart note is authorized to sign it.

Can a Nurse view/edit the unsigned Chart Note?
Yes, the nurse can view the unsigned chart notes from the 'Home > Chart Notes' section. If authorized, they can edit the chart note sections they are working in.

Can one Practice Member access/modify/finish another Practice Member’s unfinished chart notes?
Yes, you can do this from the 'Home > Chart Notes' section. If you would like another Physician to sign the Chart Note, you can do so using the 'File for Review' feature. The detailed steps are available at this link.

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

Can I upload a file over 10 MB? Is there a limit on the file upload size?
The size limit for the Document Section is 40 MB per document. There is no restriction on the number of documents you can upload.

I have a supervisor who wants to review the chart note before signing. Is this possible?
Yes, you can enable the 'Co-Sign' or 'File for Review' feature for allowing other Practice Members to sign your Chart Note. The 'Co-Sign' feature requires both you and the other Member to sign. You can file the Chart Note for co-signing from the 'Patient Dashboard > Encounters' section using the 'To be Co-Signed' option.

Additionally, you can also auto-assign co-signers under the Settings > Encounter > Preferences > Auto Assign Co-Signer' section.

The 'File for Review' option requires only the other Member to sign the chart note. Go to the 'Patient Dashboard > Encounters > Unsigned' section. Click on the 'More Option' icon (3 dots) and choose 'File for Review'.

Can I start an encounter without having an appointment scheduled?
Yes, you can start an encounter without an appointment using the below steps:

  1. Navigate to Patient's 'Dashboard > Encounters' section
  2. Click the '+ New Encounter' button. This will open the 'New Encounter' window
  3. Choose the required 'Chart Type'
  4. Click the 'Create' button

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:

  1. Navigate to 'Settings > Templates' section
  2. Click on the 'More Options' icon available for the template and choose 'Edit'
  3. 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.

How do I access a patient from multiple facilities?
To see Patients in multiple facilities you need to associate the Patient with those facilities.

  1. Navigate to the 'Patients' section
  2. Search and select the Patient
  3. Edit Patient 'Demographics' and under the 'Facilities' field, select the facilities to which you want to associate the Patient.
  4. Click the 'Update' button

Is there a way to retrieve Previous versions of chart notes?
Chart notes will be auto-saved for every minute when there is a change in data. You can retrieve this saved data of chart notes by following the below steps.

  1. Navigate the Patient 'Dashboard > Audit Trails' section.
  2. Click on the download button associated with the saved audit to download the chart note version saved at that time.
  3. Copy the data from the downloaded text file and paste it into the respective sections of the chart note.

How to share encounter notes with the Patient?
Once you sign the Chart Note it gets auto-updated in the Patient's PHR account. If the Patient doesn't have a Charm PHR account you can send it to them via SMS.

  1. Go to 'Patient Dashboard > Encounters' section.
  2. Select the encounter you want to share and click on the 'Send' button.
  3. Choose 'Clinical Summary to Patient by Text' and click 'Okay' to confirm.

Note: You can share clinical summaries through text only if your Practice has enabled the 'Text/Voice Notifications' add-on in Charm.

What sections of the chart note does the visit summary share?
Please configure the 'Settings > Encounters > Visit Summary' section to share with the Patients. Members with the necessary role privilege can enable or disable it.

How to add missing diagnosis codes to a signed chart note?
To edit signed encounters you need to unlock them first.

  1. Go to the 'Patient Dashboard > Encounters section.
  2. Choose the signed encounter and click on the 'Unlock' button.
  3. Enter the 'Reason' and click on the 'Ok' button
  4. The unlocked encounter gets listed under the Unsigned section.
  5. Make the required modifications based on your requirement.

Note: If you enable the 'Unlock' option in the 'Settings > Encounters > Preferences' section, you can view the Unlock button. You can request your Practice Admin to enable it for the Practice.

How do you know the available stock quantity in the inventory while prescribing a drug or supplement?

  1. Go to Settings > Inventory > Inventory and Vaccine Settings section
  2. Choose 'Yes' for the 'Show available stock quantity of Drugs & Supplements in Encounter' field.
  3. Click on the 'Save' button

Once configured, the Encounter displays the available stock quantity of Drugs & Supplements.