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Hello and welcome to Click4time’s training video on Electronic Charting and SOAP Notes.
At Click4Time, we’re always working hard to enhance our Online Booking and Scheduling
system to meet the changing needs of the health and wellness industry. Secure and flexible
Electronic Charting and SOAP Notes represents our continued commitment to supporting efficiency
and quality of care in your practice.
Lets dig in and see what all the fuss is about.
First off, we recommend using Chrome, Firefox or Safari browsers for the best experience.
Using other browsers may result in issues with the layout or functionality of the charting
system.
Electronic Charting is accessible and fully functional from your desktop, laptop, tablet
or smartphone browsers.
The Electronic Charting system is made up of 2 main areas
1. Chart Templates, which are created by service providers or practitioners, as a quick start
when creating a patient’s chart or treatment notes.
2. And Client/Patient Charts, which are the chart entries or SOAP notes linked to each
client/patient’s record.
In order to use e-Charting, the Owner of the clinic or business, will first need to enable
the functionality and agree to the terms and fees. To activate Electronic Charting go to
Settings / Configuration / e-Charting and move the slider to “YES”, then “Apply
Changes”.
There are additional confidentiality and Enhanced Audit Trail settings available to Owners,
which I’ll cover later in the video.
Once an Owner has activated e-Charting, each Service Provider / Practitioner who chooses
to use Electronic Charting, must enable the feature from the e-Charting section of their
profile in Settings / Service Providers.
Now that Charting has been activated for the Service Provider, let’s look at creating
a chart template that can be accessed from the patient’s profile or appointment screen
when creating a patient’s chart.
Each Service Provider can setup his or her own Chart Templates to speed up the charting
process. As a Service Provider / Practitioner, you
will most likely have one or more chart templates for different modalities or treatments, with
a specific order in which patient data is recorded.
An important concept here is that these are simply templates. When you create a chart
for a patient and choose one of these templates, you are copying the blank template from the
library of Service Provider Templates. Any changes you then make to the chart in the
patient’s screen will not affect the original chart template in the Service Provider’s
profile.
Let’s make a Chart Template. Select “Add New Chart Template”.
Give your template a name. Name it something unique and meaningful so that you will recognize
it amongst all other templates shared by your colleagues.
Do keep in mind that the Chart Template page and the Client Chart page are automatically
saved as you add sections or fill in data. If there is an interruption in your connection
during the charting process, your work will not be saved until your device has reconnected.
Templates can be Shared or Private. This means, as a service provider you can choose to share
your skillfully crafted template with your colleagues or save it for your own use. A
shared chart template may be useful if, as a clinic or business, you have a standard
order of questions or charting components that every staff should be working from.
Now to build the template, from the “Add Chart Section” pull down, choose the section
that best fits the type of data you want to collect. Don’t worry about the order of
the sections, you’ll be able to order those using these up/down arrows later.
Only add a Note at this point, wait till after explaining all section to add the others.
If you add a section by mistake, simply delete it with the trash icon.
Don’t fill in any data when creating templates, you will be doing that from the client/patient
record page only.
We’ve provided several chart intake sections commonly used by today’s health & wellness
clinics and businesses. The flexibility of the template system lends itself to unlimited
possibilities of custom charts that you can update or change as often as needed.
Although we’ve given these sections names, you can change those to suit your own needs.
These Chart Sections include:
• Chief Complaint - the primary symptom that the patient states as the reason for
seeking care. • Note - A multi-line text field.
Notice that the sections are being added from the top of the page, so if you already have
an order in mind, think about adding the sections starting with the last in that list, working
your way to the first section, being at the top. This will save you a little time later.
• Short Note – A single line text field. • Vitals - Typical vitals metrics with options
to display in metric and imperial units • Anatomical Diagrams that can be annotated
with drawings or markers with notes. We’ve provided some default images that should cover
the needs of most, but if none of those apply to your practice, you can upload your own
diagram or image to the template. The flexibility is endless.
• SOAP Notes – Where each of the 4 components includes a text box.
• Assessment Scale – a scale from 1 to 10, which can be used to measure anything
really but most commonly to measure a patient’s discomfort or pain.
• The next 4 items (Check Boxes, Dropdown, Multi-Select and Range or Values) are custom
inputs where you can add your own options or labels to the form.
o These are really easy to setup, let’s look at the check boxes for example.
o Give the section a name, and in the text field below the name, type in the labels to
be assigned to each check box, where each line of text is a new box label.
o Keep in mind you’re just creating the template here, so you won’t see the check
boxes or other custom input fields in their usable form until you create a chart and access
the template from a patient/client’s record.
There’s one section that’s not listed in the template builder, the Upload Images
or Documents. This section is only available from the Client’s chart page. The reason
being, you cannot upload a document or file to a template, since a shared template would
display that document in the template, which just doesn’t make much sense really. So
you would only add that section to a client’s chart when it’s needed, not as part of a
template.
Now that you have your sections listed in your template, you can use the arrows on the
right to switch the order if needed.
As you can see, it’s super easy to create any number of Chart and SOAP templates to
fit your needs.
It’s worth mentioning here that Service Provider Chart Templates can be accessed and
edited by users with Clinic/Company Owner, Administrator or Receptionist permissions.
But, patient chart information is only accessible by the chart creator, any other staff the
creator grants permission to and Owners.
Now that you have at least one chart template, let’s see how to use it when creating a
chart for a patient’s session.
There are 2 ways to create and edit a patient’s chart.
1. From the related appointment details screen in the company calendar, and
2. From the patient’s record in the Clients tab
Lets talk briefly about the flow of appointments and charting your patient’s progress.
Generally speaking, and it may be different for your practice or business, a chart would
be linked to a patient’s appointment. So, from the company calendar you would either
book the session or access an existing booking.
From the appointment details screen, go to the e-Charts section to create or manage the
chart entry related to the session.
In the charting page, there are two buttons to get you started, “Create a New Chart”
and “Add Health Alert”.
The “Add Health Alert” button allows you to create a highly visible notice about important
health information. The notice will always display at the top of the patient’s electronic
chart, whether accessing the file from an appointment or the Clients tab.
Anyone can access and edit or delete this alert. And by anyone I’m referring to Owners,
Administrators, Receptionists or Service Providers of the clinic/business.
Now let’s create an electronic chart for this patient, select “Create a New Chart”.
From the drop down you can create a chart from scratch using the available chart sections,
similar to creating a template, or you can choose from the previously saved templates.
The e-Charting sections dropdown, accessed from a patient record, has an additional option
that isn’t available from the templates screen, as I mentioned earlier, the “Upload
Images or Documents”. This section allows you to upload and attach files to a chart.
The supported file types are PDF, JPG, JPEG, PNG, and GIF.
As a side note here, keep in mind that all the data typed into the chart is auto saved.
Also, charts are date and user stamped as it’s created or modified, so It’s critically
important to be sure you are logged in to your own account to maintain the integrity
of the chart audit trail. A quick way to confirm you’re logged in to the correct account
is to look for your email address at the top of the page.
I’m going to choose the custom chart template I just created in the service provider tab.
When selected, the template is added and ready for you to input your patient’s data. From
here you can also rearrange, add, rename or remove sections from the chart. Modifying
the chart template from the appointment or client record screen, does not affect the
original template stored in the Service Provider’s profile.
Once the chart has been created, you will want to assign individual permissions to access
the chart. By default the chart creator always has permission to view and edit the chart,
but they may want to share the chart with colleagues within the clinic or company. Permissions
are assigned at the bottom of chart. Owners always have full access to the chart data.
Charts will remain in a Draft state until Locked by one of the assigned service providers.
Locking a chart will add a notation in the footer “Locked & Signed by” including
the name of the service provider, date and time the chart was locked.
Once a chart has been locked, the original data can no longer be edited. Only addendums
may be added at that point, again to maintain the integrity of the electronic chart.
To add an addendum to a locked chart, select the “Add Addendum” link. Addendums are
also date and user stamped.
Now that there are charts related to the patient, you can access those from the Clients tab
or from the appointment screen. Accessing the full chart list from the link in the appointment
screen is essentially the same as opening the Clients tab - then the patient profile
and finally the e-Charts section. So you save a few clicks or taps by doing it from here.
A patient’s chart history is stored in chronological order, listed from the most recent at the
top, to oldest at the bottom.
In this screen, only charts the user has permission to view will appear in the list. From here,
charts can also be downloaded as PDF documents to your computer or mobile device.
At the top of the page, there’s also a Search section. Here you can quickly search through
a potentially long list of charts. You can search by any combination of
• The service related to the session the chart was create for
• The Status, Locked or Draft • Section Type. When you add a chart section,
Note, Anatomical Diagram, Assesment Scale etc. even though you may give it a new title,
it’s still referenced as the original type for the search purpose.
• Keyword Search, that searches any text string in any of the chart sections within
a chart. The exception is the uploaded documents or files, which it cannot search through.
• And Date Range of course. Again, this will only search through the charts
the user has permission to access.
Once the Search results are filtered, you can expand the charts to view the data or
choose to export the data as a PDF using the PDF All button.
One of the major game changing benefits of electronic charting is quick access to patient
data from pretty much any modern device with a browser connected to the internet. We take
the security of that information very seriously. Since charts may contain some of the most
personal information about your patient, everyone involved needs to do their part to ensure
that data remains secure.
• First off, our system uses 256-bit encryption to ensure no one is peeking in on your patient’s
data.
• Click4Time follows the recommended guidelines of federal and provincial/state policies and
standards related to the processing and storage of Personal Identifiable Information.
• Click4Time’s personnel do not have access to patient electronic chart data, ever.
• Charts display a detailed audit trail including
o Who created a chart and when o Who last modified a chart and when
o Who locked a chart and when o Who added an addendum and when
• We also offer an optional layer of auditing whereby the owner can choose to activate the
Enhanced Audit Trail, which includes o Who downloaded or printed a chart and when
o Who edited any chart entry and when, not just the last modified information
• Security warning when downloading charts to remind the practitioner of the potentially
sensitive nature of the information being downloaded to their personal computing device.
• A customizable Print and Download Confidentiality Statement that displays at the footer of all
downloaded charts.
Beyond the measures Click4Time has taken to ensure the safety and security of the data,
it’s important that service providers using the system also take steps to do the same.
• Never share your login account credentials with anyone
• Lock the screen of your device or computer when not in use
• Log out of the system if away from your device for extended periods
• Immediately report a suspected breach to the appropriate person or governing body
• Also report any suspected breach or data security concern to Click4Time
Well that covers it. As you can see we’ve created quite the system that will continue
to grow with you and your practice for many years to come.
If you have any unanswered questions or need help with getting setup, please don’t hesitate
to contact us by emailing support@click4time.com or calling us within North America at 1-877-425-4254
Ext 1 or Internationally at 1-604-210-1039 Ext 1.
We always look forward to hearing from you.
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