© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 1 Guided Practice Exercises Systems Training Charting October 2009

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 2 Charting Add charting For Acute Care Only A. Treatment Screen  1. Open the Treatment Screen  2. Right-Click the patient listing and select CHART TX or click the patient listing once and select CHART TX icon at the top of the screen  NOTE: Always make sure that you have selected the correct patient before adding the chart note. 1 A 2

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 3 Find a Patient Daily Schedule pane – Choose a patient (For Out Patient only) B. Daily Schedule Pane  1. Right-click on a scheduled appointment  To chart a treatment for the patient, select CHART  To edit the scheduled appointment, click EDIT  To cancel the appointment, click CANCEL  To view the patient and his/her information on the main MediLinks screen, click SELECT PATIENT  To print the details of the scheduled appointment, click PRINT APPOINTMENT  NOTE: This capability is only available to users who have appointments scheduled 1 B

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 4 Charting Add charting C. Patient Find (For Rehab only)  1. Search for patient  2. Right-Click the patient listing and select ADD CHARTING  NOTE: Always make sure that you have selected the correct patient before adding the chart note. 1 C 2

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 5 Charting Add charting D. Patient Charting tab  NOTE: The patient must be in context  1. Click the ADD CHARTING icon on the patient’s Charting tab 1 D

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 6 Charting Add a template – NEW TEMPLATE icon In the Charting Entry screen:  1. Click the NEW TEMPLATE icon  RESULT: Template Selection window appears  2. Click on the desired template to highlight it  If needed, sort and group to identify the desired template  3. Click the OK icon to open the desired template  If you double-click the desired template, it will open for use  NOTE: The Template Selection window will appear automatically if the following conditions are met:  TEMPLATE CHARTING is set as the DEFAULT CHARTING START PAGE in your User Configuration screen settings  No template favorites are configured 1 2 3

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 7 Charting Configure favorites In the Charting Entry screen:  1. Click the FAVORITES icon  NOTE: Favorites need to be configured per facility.  2. Select a row and click the ADD icon  Select the desired template to highlight it and click OK to add it or  Double-click the desired template to add it  3. Click the USE icon to open the desired template  NOTE: In the future, you only need to press [ALT]+[#] on the keyboard to open your “favorite” template – up to ten (10) favorites are allowed 1 23

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 8 Charting Initiate documentation To begin documenting the note:  1. Check the AUTO-RUN TEMPLATE check box  RESULT: The first available charting object (branch code) will display for documentation  NOTE: With this checked, the template will automatically advance you in order through each consecutive branch code until all of the branching objects are resolved OR  2. Double-click on the desired “Branch” entry object  RESULT: The selected branch code will display for documentation  NOTE: Once the branch code has been completed, the template will wait for you to choose (double-click) the next branch to complete until all the branching objects are resolved. This approach allows you to document in the order that you choose. 1 2

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 9 Charting Branching logic codes – data entry There are two types of branching logic codes:  1. Text Entry – text and numeric responses  A. Use the keyboard to enter the text and/or numeric characters  B. Click the OK button with the mouse or press the [ENTER] key on the keyboard to proceed to the next branch code OR  2. Selection List – selected responses from preset lists  A. Mouse: Click the desired item, then click the SELECT button  B. Mouse: Double-click the desired item – advances you to the next branch  C. Keyboard: Press the arrow keys to select the desired item, then press the [ENTER] key to proceed to the next branch code 12

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 10 Charting Branching logic codes – interaction with the screen  1. CANCEL icon – exits current branching logic sequence  Use to exit the branch without documenting (e.g., selected the wrong branch by mistake or if you are not yet ready to document)  NOTE: Canceling the branch does not retain the documentation but it does allows you to start the branch over at another time  2. INTERRUPT icon – exits the entire chart note  Use to save an incomplete chart note  NOTE: If the interruption occurs during the branching logic sequence, the documentation from that sequence is not saved  NOTE: Interrupting the branch allows you to start the branch over at another time  3. ERASER icon – backtracks in the current sequence in order to change a previous entry 12 Preview Do not type or edit in this screen! Entry Screen Enter data here 3

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 11 Charting Free-text documentation  1. Place the cursor where you want to add free-text documentation  Any text that is typed as free-text will not be captured in observations (memory) for use in other places (e.g., the Care Plan flowsheet); it will only remain in this chart note  NOTE: Do not fix branching code mistakes with free-text without fixing your observation entry as well. Otherwise, your changes will not be captured appropriately 1 2 Free-Text Place your cursor in the body of the template and type additional notes 3

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 12 Charting Add a mini-template to a chart note Begin with an open charting template  1. Place the cursor where you want to insert the mini- template  Can be in the body of the charting document or at the beginning or the end of the chart note  2. Insert the mini-template  A. If the desired mini-template is a favorite, press [ALT]+[#] on the keyboard or click the FAVORITES icon  B. Click the NEW TEMPLATE icon and select the desired mini- template from the Template Selection window  3. Document on the mini-template 1 2B Insert a Mini-Template Place your cursor in the template and insert the “mini” 3 2A

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 13 Charting To delete a mini-template from a chart note  1. Highlight all of the text and entry objects from the inserted (and unwanted) mini-template  2. Delete the highlighted mini-template and text  A. Right-click with the mouse and select DELETE  B. Press the [DELETE] key on the keyboard  C. Press the [BACKSPACE] key on the keyboard 1 2A

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 14 Charting Interrupt a chart note – 1  1. Click the INTERRUPT icon at the top of the screen  NOTE: This icon is available only if the branching logic Data Entry screen is closed  NOTE: A chart note can be interrupted at any time  NOTE: All data within the chart note are saved and closed to be completed at another time  NOTE: An interrupted chart note = an incomplete chart note (i.e., no charges billed, no data captured); the chart note must be signed for the data to become a part of the patient’s record 1

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 15 Charting Interrupt a chart note – 2  1. Click the INTERRUPT icon within the branching logic Data Entry screen  NOTE: All data within the current branching logic sequence (see the red A for an example) are lost  NOTE: All other data already existing within the chart note is saved and closed to be completed at another time  NOTE: The interrupted branching logic sequence can be completed at another time – the opportunity to enter data is not lost  NOTE: An interrupted chart note= an incomplete chart note (e.g., no charges billed, no data captured); the chart note must be signed for the data to become a part of the patient’s record 1 A

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 16 Charting Sign & Finish tab (Students must ALWAYS have CI approval first)  1. Enter the time you began your appointment with the patient in the TASK COMPLETED field  NOTE: You must use military time (24:00)  2. Enter the total billable AND nonbillable time in Session duration  3. Verify the billed items for the chart note  4. Click the SIGN button to complete the chart note

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 17 Charting Review charting There are two ways to review an existing chart note: 1.View Charting – opens a read-only view  A. Select the desired chart note record  B. Click the VIEW CHARTING icon  NOTE: You can also double-click the desired chart note record  NOTE: This view provides access to the Edit Charting screen 2.Edit Charting – opens an editable view  A. Select the desired chart note record  B. Click the EDIT CHARTING icon 1A 1B2B 2A

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 18 Charting View charting View selected documentation  1. Toggle between the tabs to view the data from the chart note View other documentation  2. Cycle through the available chart notes Edit the chart note  3. Click the EDIT CHARTING icon Add an annotation  4. Click the ANNOTATIONS icon

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 19 Charting Edit charting View selected documentation  1. Toggle between the tabs to view the data from the chart note View other documentation  2. View previous chart notes through the VIEW PRIOR NOTES icon Edit the chart note  3. Make any free-text edits within the chart template  NOTE: You can add other templates or mini-templates to the note Add an annotation  4. Click the ANNOTATIONS icon

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 20 Charting View prior chart notes This window is available when you are documenting a new chart note and allows you to review the patient’s prior chart notes without having to leave the screen  1. View charting by Account ID or by Medical Record Number (MRN) – select in the drop-down menu  2. Select the desired prior note to view  3. View the documentation associated with the selected prior note  NOTE: No charges will display  4. Click the OK button when done viewing prior notes  NOTE: This screen ONLY shows signed documents

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 21 Charting Locate interrupted charting – 1 Patient Charting tab  1. Select a patient to display (using Find Patient, etc.)  2. On the patient’s Charting tab, interrupted chart notes are bolded and italicized to distinguish them from others  3. The Charting tab display can be filtered to display interrupted charting only  NOTE: Select the Interrupted radio button  4. Click the EDIT CHARTING icon to finish the desired interrupted chart note

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 22 Charting Locate interrupted charting – 2 Task List  NOTE: For this Task List Category to display, it must be enabled in each staff member’s User Configuration settings (see letter A)  1. Expand the INTERRUPTED CHARTING task list category (click on the + button)  2. Select the patient whose interrupted charting you wish to complete  NOTE: You can click on the patient in the list or select the patient using the right-click menu 1 2 A

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 23 Charting Locate interrupted charting – 2 (continued) Task List  NOTE: If the Interrupted Charting Task List Category is enabled, MediLinks will notify you that you have interrupted charting when you attempt to log out from the main screen  1. Click the YES button to open the Interrupted Charting Task List Category and view your interrupted charting  1A. Select the patient whose interrupted charting you wish to complete  2. Click the NO button to finish logging out of MediLinks without completing the interrupted chart note(s) 1 1A 2

© 2008 MediServe, Inc. All Rights Reserved.MediServe Confidential 24 Charting Resolve interrupted charting Once you are inside of the interrupted chart note, document as you would in any new chart note:  1. Check the AUTO-RUN TEMPLATE check box  NOTE: You will start documenting at the first unresolved branching logic code OR  2. Double-click on the desired branching logic code to continue documenting  3. Once finished documenting, sign and finish the note  NOTE: A note can be interrupted as many times as needed 1 2 3