Help : Manual Charting

The main text block is where you will enter your subjective and objective notes. You can also access Quick Add and Chart Part template/auto-fill tools by typing in the main text block.

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.

Help: Charges

  • 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.