Charting Overview

If a patient has an appointment today, or a provider has opened a chart note using the Visit History chart section, visit-related buttons for charting appear under the “Visit” headline in the lower- left navigation of the chart.

Click on a chart note title to open it. You will see the chart note’s custom navigation buttons.

Use the chart note navigation buttons to browse the chart note and begin entering information about the exam.

Chart note protocols are made up of different components, and you can create different protocols for different visit types and (optionally) for each provider. A typical chart note protocols might contain vitals, history, SOAP sections, and sections for creating orders.

As clinicians enter vitals, select diagnoses and procedures, or enter and fulfill labs, orders, and prescriptions, the PCC EHR automatically adds that information to the patient’s historical record. Any information you mark in a chart note will later appear on the Visit History screen.

When finished, providers click “Save” to save their work and click “Schedule” to return to the schedule.

Multiple nurses and other clinicians may open, edit, close, and reopen a patient’s chart and contribute to the details of a visit.

When the visit is complete, a user can click “Bill” to review billed diagnoses, add additional procedures, and send billing information to the Partner practice management system.

Refresh and Conflicts: If multiple users in your office open and make changes to a patient chart, then the “Save + Refresh” button will turn yellow. Click the button to save your own changes and display any changes made by other users. PCC EHR records changes to a patient chart independently, by user; multiple changes can not conflict.

Chart Note Navigation

When charting a visit, each button on the left corresponds with an anchor point on the chart note. You can navigate through a chart note in three ways:

Click the anchor buttons to jump to particular sections of the chart note.
Scroll up and down using the scroll bar.
Use the “Next” and “Previous” buttons to step through each section of the chart note.

Here are some related articles in Clinical Tasks > Chart a Visit:

Chart a Visit in PCC EHR
This demo walks you through the charting experience in PCC EHR, focusing on many of our pediatric-specific features and workflows.
Chart with Answer Memory, Last Answer, and Your Custom Auto-Notes
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Chart with Multiple Protocols
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Chart with Answer Memory, Last Answer, and Your Custom Auto-Notes
PCC EHR has several unique tools that help you enter notes on a chart faster. This help article lists those features and includes procedures and links for configuring them.
Review and Edit Sibling Charts
You can open several sibling charts and work on them at the same time, flipping back and forth between them as needed.
Chart Note Protocols
Chart notes are made up of different sections, or elements, that a particular visit type needs. The custom chart note is called a protocol. You will see a different protocol for different visit reasons, and providers may have their own, custom protocols.
Chart a Visit in PCC EHR
Read the procedure below to learn about each step of a typical visit in PCC EHR.
Delete an Encounter from a Patient’s Chart
You can delete a visit created in error in PCC EHR. When you delete a visit, all vitals, chart notes, orders, and other items created for the visit are removed from the patient's record.
Search the Patient Visit History or within a Charted Encounter
You can select Find from the Edit menu to search through a visit chart note, the medical summary, or another protocol-based chart section. You can also use your operating system's keyboard shortcuts (ctrl+F on Windows or Linux, command+F on Macintosh).
Spell Check in PCC EHR
PCC EHR automatically checks your spelling as you type.
Find and Refine Diagnoses as You Chart
PCC EHR can help clinicians select a more specific diagnosis description. After they select a diagnosis, they can use a pull-down menu to refine the selection.
Chart Amendment Requests
If a patient or family requests that you amend information in their chart, you can now record that amendment request. For example, if a family objects to a diagnosis in the patient’s chart, you can create an amendment request on the visit for that day. While viewing a chart note (or phone note or message […]
Hide Sensitive Diagnoses from the Patient Portal and Patient Reports
Contents1 Hide a Single Patient’s Diagnosis or Problem2 Where Does a Locked Diagnosis Still Appear? How Do I Send Records?3 Configure Default Hidden Diagnoses In PCC EHR, you can mark any diagnosis or Problem List, allergy, or Family Medical History list item as private. A private or “locked” diagnosis will not appear on patient reports […]
Dr Hagan On Performing Well Visits via Telemedicine
Can pediatricians perform well child visits with telemedicine? Will practices be paid? Dr. Hagan explains Well Visits via Telemedicine and provides his recommendations and ideas.
Signing in pocketPCC
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Create and Manage Forms in PCC EHR
Start creating your own patient form letters in PCC EHR.
Configure Provider Signatures for Patient Forms
Contents1 Configure User Permissions2 Access Signature Configuration3 Add a New Signature Image4 Set Signature Generation Permissions You can upload provider signatures, set permissions for who is allowed to generate them, and include them on patient forms in the Forms Configuration tool in PCC EHR. Your practice will need to be live with the Forms Configuration […]

Chart Note Navigation

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