Chart a Visit
When a patient has an appointment, their chart displays a chart note for charting the visit. Multiple providers (such as a nurse followed by a doctor) may open the chart, complete sections of the visit chart note, and review the patient’s chart history while they work with the patient.
The help articles below describe how the charting screens work, outline a typical visit step-by-step, and describes how chart notes are customized for each visit type and each provider.
Watch this video to learn how to chart a visit using PCC EHR, including a review of basic components, diagnoses, and autonotes.
- Read the procedure below to learn about each step of a typical visit in PCC EHR.
- 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.
- 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.
- You can open several sibling charts and work on them at the same time, flipping back and forth between them as needed.
- 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.
- 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.
- 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).
- PCC EHR automatically checks your spelling as you type.
- 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.
- 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 […]
- 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 and it will not appear in the patient portal. Hide a Single Patient’s Diagnosis or Problem When you want to hide a single diagnosis […]