Help : Charting
Open an existing encounter/SOAP note by double-clicking on the note title. Open a new note by clicking on the plus icon in the top right of the encounter note block.
Help: Manual Charting
Help: Diagnoses - Assessment
- Quick Add prefix: dx_
- Search diagnoses database by: diagnostic name, nickname(s), ICD-10 code
To manually add a new diagnosis to the note, type search terms associated with the diagnosis (including all or part of the diagnostic name, nickname(s), and ICD-10 code) in any order in the "- Find DX to Assign -" bar in the Assessment box. Note that the EMR uses a subset of the ICD-10 diagnostic codes, which can be expanded or modified in the Administrative section.
Diagnostic codes that are part of a note will automatically appear on any billing or insurance forms generated from the note. Once generated, billing and insurance forms can be manually edited.
Right-click any diagnosis that has been added to the note to:
- Make it the primary diagnosis,
- Add it to a patient's past medical history,
- Remove it from the note, or
- Manage the diagnosis definition (administrative function).
If it is a diagnosis for which additional information has been added to the system, you can also use the right click menu to add to the note:
- A description of the diagnosis,
- Common workup,
- Differential diagnoses, and
- Patient education.
Help: Plan - Prescriptions, Orders, Vaccines
The plan box is used to add prescriptions, orders, vaccines. If enabled, it may also be used to add lifestyle rxs, supplements, and alternative plan items.
Help: Add Prescription Rx
- Keyboard shortcut: Ctrl+shift+r
- Quick Add prefix: rx_
- Search database by: drug name, brand, ingredients, strength, delivery method, form (tab, cap, etc.)
To manually add a new prescription to a note, click "add prescription" in the plan menu or hold down the Ctrl and Shift keys and press "r". Search in the field provided for the drug name, brand, ingredients, strength, delivery method, or form. Partial words or numbers are fine and the system will search as you type. By default, the search will return drugs from your preferred short list. If none match, or if you enter a “+” in the search bar, it will instead return all matching entries from the full VA National Formulary database. When you select a prescription, you will add or edit prescription details, and then click "Complete" or "Complete and Fax" to add it to the note.
Once a prescription has been added, you can right click to renew, discontinue, replace with new, delete, or edit the prescription, learn more at Medline Plus, or create a faxable form. Also see Medications help.
Help: Add/Schedule Orders
- Keyboard shortcut: Ctrl+shift+o
- Quick Add prefix: or_
- Search by: title, subtitle, category, code, nickname, description
To manually add orders (labs or scans) to a note, click "Add/Schedule Orders " in the plan menu or hold down the Ctrl and Shift keys and press "o". You can select from the patient favorites and common orders that appear automatically below the search bar, or type to search for the order title, subtitle, category, CPT or ICD-10 code, nickname, and/or description using whole or partial words. The system will search the full CPT or ICD-10 code book as you type and will, by default, return results from your preferred short list. If none match, or if you enter a “+” in the search bar, it will instead return all matching entries from the full code set.
By default, any diagnoses in the encounter note when the order is added will appear in the order form. Remove a diagnosis from the form using the [x] button to the left of the diagnosis. Add diagnoses using the search box provided. Add notes, if desired, or leave default text.
Once an order has been added, it appears in the note and in the Open Orders block.
Help: Add Vaccination
- Keyboard shortcut: Ctrl+Shift+v
- Quick Add prefix: vc
- Search by: name, nickname(s), brand
To manually add one or more vaccines to a note, click “Add Vaccines” in the Plan menu or hold down the Ctrl and Shift keys and press "v". This brings up the patient's vaccine history chart. Adding a vaccine to the vaccine chart makes an entry in the chart and the encounter note's Plan block. Once a vaccine has been added, you can right click to edit or delete the entry.
Help: Add Alternate Plan Item
- Keyboard shortcut: none
- Quick Add prefix: AP
- Search by: name, nickname(s), description
To manually add a supplement, lifestyle rx, recommendation, or other alternate plan item to the note, you must first have the desired alternate plan item(s) in your database. You can add these in yourself via Admin -> Manage -> Alternate Plan Options or, upon request, we can load a relatively extensive supplements database in for you.
Once these are in your system, add an alternate plan item from your database to a note by hovering over the plus icon in the Plan box of an open encounter note, and then clicking on the desired alternate plan type. In the search bar that appears, search by name, nickname, and/or description in the search bar that appears. Search terms may be entered in any order and the system will search as you type.
- Quick Add prefix: ch
- Search by: name, nickname(s), CPT code
To manually add charges, click the plus button in the Charges box. Then search for a charge by all or part of the charge's name or nickname. The list of available charges can be modified in the administrative section.
Once it has been added to the note, right-clicking on a charge allows you to edit, remove, or refund it. Note that charges are the only part of the note that remain editable after the note is signed.
Help: Quick Charting
You can access MD HQ's quick charting tools (Quick Add, Chart Parts, and prompted templates) simply by typing in an encounter note's main text block, helping you to chart faster than ever before. And the system searches for potential matches as you type, so there is no need to memorize lots of complicated shorthand to use these tools.
Help: Quick Add
The Quick Add function provides a way to search for and add any diagnosis, prescription, order, alternate plan item, vaccine, facility, or charge to the text of the note AND to the relevant encounter note block (Assessment, Plan, Charges) AND, if applicable, the relevant part of the patient's chart (Medications or Supplements List, Vaccine Chart, Preferred Facilities, etc.).
To search the database for the entry you would like to add, first type the applicable two-letter prefix (see table, below, this which tells the system which database to search), followed by an underscore.
Immediately after the prefix and underscore, type in one or more search terms, separating multiple search terms with underscores, not spaces (a space ends the search). Once you've typed in the prefix, underscore, and at least three characters, the system will display potential matches to the left of the main text block.
Select an entry using your mouse or, to select an entry from the list without using the mouse, press the up arrow to select and add the topmost entry or toggle to the list by pressing the left, right, or down arrows on the keyboard. Within the list, the down or right arrows move down the list, and the up or left arrows move up. Press enter to select.
This will information about the selected entry to the main text block, and add a Suggested Action above the Assessment block on the right hand side of the note. Click on a Suggested Action to take that action (adding the item to the Assessment, Plan, or Charges section of the note and/or updating the relevant part of the patient's chart), or click on the red x to dismiss.
Quick Add Prefixes
|Category||Prefix||Search By||What Happens when you Select an Entry?|
|Actions||dx_ = diagnosis||Diagnostic name, nickname(s), ICD-9 code
||- Text added to main text block: diagnosis name and CPT code
- Suggested action: diagnosis
Accepting the suggested action (by clicking on it) adds the diagnosis to the note's Assessment block.
or_ = order
xr_ = order (x-ray)
|Title, subtitle, category, nickname, description
||- Text added to main text block: order title
- Suggested action: order
Accepting the suggested action (by clicking on it) adds the order to the note's Plan block and pops up the Add/Schedule Orders" dialogue.
|rx_ = drug||Drug name, brand, ingredients, strength, delivery method, form||- Text added to main text block: drug name
- Suggested action: prescription
Accepting the suggested action (by clicking on it) adds the prescription to the note's Plan block and pops up a "+ Complete and Add Rx" dialogue.
|ap_ = alternate plan item
||- Text added to main text block: alternate plan item name
- Suggested action: supplement prescription, recommendation, etc.
Accepting the suggested action (by clicking on it) adds the supplement prescription, recommendation, or other alternate plan action to the note's Plan block and pops up a "+ Complete and Add" dialogue.
|vc_ = vaccine||Name, nickname(s), brand
||- Text added to main text block: vaccine name
- Suggested action: vaccine
Accepting the suggested action (by clicking on it) adds the vaccine to the Plan block and pops up an "+ Add New Vaccination" dialogue. The vaccine will be entered into the next open dosing for that vaccine in the patient's vaccine chart.
|ch_ = charge||Name, nickname(s), CPT code
||- Text added to main text block: charge name
- Suggested action: charge
Accepting the suggested action (by clicking on it) adds the charge to the note's Charges block.
|Facilities||lb_ = laboratory||Name, street address, city, state/province, postal code, phone number||- Text added to main text block: facility/specialist name, address, phone number|
|ph_ = pharmacy|
|sp_ = specialist|
rd_ = radiologist
Help: Chart Parts
Chart Parts is MD HQ's flexible, accessible answer to a traditional templating system. A Chart Part can be used to auto-complete a commonly-used phrase, add a set of text prompts, add a combination of actions, or add any combination of text and actions to the note. You type the name or nickname of the Chart Part that you're looking for into the note's main text block, the system searches as you type, and potential matches appear to the left. To select an entry from the list without using the mouse, press the up arrow to select and add the topmost entry or toggle to the list by pressing the left, right, or down arrows on the keyboard. Within the list, the down or right arrows move down the list, and the up or left arrows move up. Press enter to select.
The system comes pre-loaded with commonly-needed Chart Parts or you can easily build your own.
Help: Using Chart Parts
A Chart Part is accessed by typing all or part of its name or nickname in the main text field of an open encounter note (or another free text field that supports this feature, such as email notifications and reminders in the Calendar). Matches will appear to the left as you type. Click on one to select it. To select an entry from the list without using the mouse, press the up arrow to select and add the topmost entry or toggle to the list by pressing the left, right, or down arrows on the keyboard. Within the list, the down or right arrows move down the list, and the up or left arrows move up. Press enter to select.
Once selected, any text from the Chart Part template will be added to the main text block (or to the applicable free text field). In an encounter note, actions will be added as "Suggested Actions" above the yellow Assessment block on the right. Click on a suggested action to add it to the note. Click on the x to the right of any suggestion to remove it.
Help: Custom Chart Parts
Create or manage Chart Parts via the Admin drop down menu at the top of the page. Select Manage... >> Chart Parts, then click on +Add New to create your own. Note: highlighting text in an open encounter note will also give you the option to create a custom Chart Part with that text.
You must give the Chart Part a name, and may give it one or more nicknames. A name or nickname can contain any combination of letters, numbers and certain special characters, but not spaces or any of the following special characters: \ ^ % & *. Multiple nicknames should be separated by spaces.
The scope of the Chart Part refers to who may use it: just the doctor who creates it or anyone in the practice. Restricting the scope of a template makes sense, for example, when one user takes a different approach to a certain type of encounter than does the rest of the practice.
Add text that you want to appear exactly as written when the Chart Part is called. Or you can add one or more text variables, which will add patient- or encounter-specific information when the Chart Part is used. Variable names are enclosed in double brackets, as in: [[variable]].
|Variable||Text that will be Inserted in the Note|
|[[date]]||Date the Chart Part is added to the note|
|[[time]]||Time the Chart Part is added to the note|
|[[dateandtime]]||Date and time the Chart part is added to the note|
|[[soap_time_elapsed]]||Time elapsed since note created|
|[[doctor]]||Name of the user that is logged in when the Chart Part is added to the note|
|[[pt_allergies]]||A list of all of all allergies listed in the patient's file|
|[[pt_bp]]||Patient's last blood pressure reading on file|
|[[pt_bps]]||All of patient's blood pressure readings on file|
|[[pt_dob]]||Patient's date of birth|
|[[pt_dxs]]||A list of all of the diagnoses that have ever been added to the patient's file|
|[[pt_name]]||Name of the patient|
|[[pt_pharmacy]]||The patient's primary pharmacy|
|[[pt_pmh]]||A summary of the patient's past medical history|
|[[pt_rxs]]||A list of all of all medications in the patient's file, past or current, with a notation for any that are expired or discontinued|
|[[pt_note_social]]||The text that appears in the Social Notes block on the patient's dashboard page|
|[[pt_note_basic]]||The text that appears in the Need to Know block on the patient's dashboard page|
|[[pt_note_admin]]||The text that appears in the Admin Notes block on the patient's dashboard page|
Some Chart Parts are likely to consist of just short, commonly-used phrases, so that you don't need to type the same things over and over when charting, but can instead type in the name or nickname and then press the up arrow to select and add the topmost suggested match.
To add a diagnosis, drug, order/lab, vaccine, or charge or alternate plan option (supplements, recommendations, etc) to the note, select the type of action to add using the drop down menu, and search for the desired entry in the search bar. As usual, type in whole or partial words or numbers in any order, and the system will search as you type.
Remove any action by clicking the [x] to its far right.
When finished, click +Add New Chart Part.
Help: Prompted Templates
MD HQ also has a small set of prompted templates (fillable template forms) for various common encounter types, including Chem 7/Chem 8, well woman, well adult, and well child exams. More can be developed upon request.
Help: Faxing Prescriptions and Orders
Fax prescriptions from the + Complete and Add Rx dialogue, by clicking "+ Complete & Fax to Pharmacy". Once prescriptions or orders are added to the note, fax from the Plan menu by clicking "Fax Rxs" or "Fax Orders," or right click on an order or prescription in the note and select "Create Fax."
When you're completely finished with a note, click "Save and Sign" to finalize. Once a note is signed, diagnoses, plan items, and text are no longer editable, and additional diagnoses, plan items, or text cannot be added without first unsigning the note. However, signing does not affect your ability to add or edit charges. You can also append comments to signed notes
If you have the Patient Portal enabled and have opted to have encounter summaries visible to patients on the Portal, signing a note finalizes it and makes the encounter summary available to the patient. The encounter summary shows everything in the note except (1) the text (i.e., your subjective and objective notes) and (2) the charges.
Any user can be set up as someone who must or may have his or her encounter notes co-signed by another provider. This can be useful to allow a physician's assistant, nurse, or nurse practitioner, for example, to complete and sign notes that are then placed in a queue for review and co-signing by a supervising doctor.
Co-signature can be set up in one of several ways for a particular provider:
- Co-signature options never appear when the provider signs a note.
- Co-signature options always appear when that provider signs a note, but co-signature is always optional, at the option of the provider making the request for co-signature.
- Co-signature options always appear when that provider signs a note, and co-signature is required for some notes that contain designated charge types (CPT codes that you have specified), e.g., for particularly complex encounters.
- Co-signature options always appear when that provider signs a note, and co-signature is always required.
Where co-signature options appear, the provider requesting co-signature will generally have the option to submit the request to any other provider with the power to co-sign. These are doctors (or more experienced providers of any type) that we have set up as available co-signers at your request. A single provider may also be designated as the default or required co-signer for another user.
When co-signature is requested, the note appears signed with a "Pending Co-Signature" label, and the co-signature request appears in the designated co-signer's task list, or in the task list of each provider who is authorized to co-sign if "Request Co-Signature From: Any Authorized Provider" is selected. When the note is co-signed, it will show in the top right-hand corner both the signed date and user and the co-signed date and user.
Co-signing cannot be undone. But if the note is unsigned, both the signature and co-signature will be cleared.
If unsigning is enabled for your practice, you can unsign a signed encounter note, for example to add or edit a diagnosis or fix any other mistake or omission. Depending on how your build is configured, you will do this in one of two ways.
If confirmation is not required to unsign, you simply click the unsign button that appears in the note, explain why you are unsigning in the pop-up window that appears, and click "Submit Unsign Request". For records-keeping and auditing purposes, a copy of the original note will be attached to the unsigned note as a "previous signed version."
On the other hand, if your practice is set up to require confirmation from another provider, the note will initialy remained signed with a note indicating that an unsign request has been submitted. A task will appear in the task list of each other provider with authority to confirm unsigning. When the unsign request is confirmed, the note will be unsigned. A copy of the original note will be attached to the unsigned note as a "previous unsigned version" if the practice has opted to do this in addition to using confirmation of unsigning.
Help: SOAP Note "Ownership"
When a SOAP note is signed, it will automatically become owned by the signing user. This will permanently assign all charges that were added inside the SOAP note to this owner (unless the note is subsequently unsigned).
However, until the note is signed it has no “owner” and the EMR assigns co-responsibility for the note to:
- Whoever first created the note
- Whoever last updated the note (pressed the “Save” button)
- The assigned owner (assuming your configuration allows for manual assignment of notes).
This means that up to three users may show that they have an “unsigned note” in the Unsigned Notes tab of their Tasks list if the note has been created by, updated by, and assigned to different people.
For the sake of billing reports, however, the EMR will assign ownership of charges to the manually assigned owner and if there is no manually assigned owner (either because you don’t have this option available or because no owner was specified) then the charges will be assigned to the person who added the note. Once the note is signed, any charges will be re-assigned to the signing user.
Note: If you don't see an option for manually assigning a SOAP note at the top right of a SOAP screen (above the assessments block) then your build does not have this option configured. Contact firstname.lastname@example.org and request this option be turned on if you'd like to make it available.