Using emsCharts Series # 1.4 Entering a Chart Using emsCharts Series # 1.4

Entering a Chart Log into emsCharts From your Home Page choose “Patient Records” on the left Menu On the Right side of the Screen click the button “Create Blank Chart” A New Chart will be created. Any defaults set by your company will be completed to start the chart. The following screens will vary from your company screens as many fields are configurable. This will be a sample configuration.

Page 1 This is page one of a chart entry. We will break this down into various sections.

Page 1 - Menu This menu is available on all pages as you work through a chart. The “Home” at the very top will take you to your Home Page. This will close the chart. You may proceed through the pages as desired once the record has been created. The chart automatically saves when you change to a different page.

Page 1 – Top Entry You will enter any ID’s requested by your company. Two are available. These may be required. They may be numbers, letters, or symbols. The Patient Record ID is created automatically by emsCharts The Import Button is only available if a CAD import has been purchased.

Page 1 - General Complete the fields to the best of your knowledge. Review all fields that have been pre-filled. The level of care (ALS,BLS, etc) is important as it will close or open areas of the program further along. All pull down fields are configurable

Page 1 – Crew Members Up to 4 crew members may be shown Letters in the front represent their Role. D = Driver P = Primary S = Secondary T = Tertiary O = Other Other people may be entered in the box below

Page 1 - Referring Where you Picked Up your Patient May choose by Search or Pull Down Pull Down is most common places patients are taken This box may be edited in configuration to eliminate fields not needed by your service. Fields may also be added if desired.

Page 1 - Receiving Where you took your Patient May choose by Search or Pull Down Pull Down is most common places patients are taken Comment Box! Replaces end Narrative by placing comments where they belong. This avoids confusion about a comment as well as having to repeat information in a second location. This also prevents you from forgetting about this at a later time. This type of box will hold 256 characters!

Page 1 - Times May be Active X or Text boxes May turn off un-needed boxes Will automatically warn you if they are out of sequence Only use what you need Some may be set as “Required” by your service Time Zone indicated at top

Page 1 - Mileages Fields may be turned off in configuration if not needed Will calculate Loaded and Total if entered Your company needs to set protocol for # of digits entered May show Loaded Miles Only May be made mandatory Out of County Miles This box may be displayed if required in your state This does not calculate, but would be entered manually

Page 1 – Add Patient Button on Bottom of Page 1 Click to Add Patient Info to the Chart Will Bring Up New Page with Various Options These Options will vary according to configuration settings

Page 1 – Choosing No Patient This choice may not be available according to Configuration Will skip all Patient Information, Assessments, and Treatments Will allow closing of chart without any further information

Page 1 – Choosing Patient If either of these are chosen you will be taken directly to the Patient Info Section The Unknown choice will automatically complete the Unknown check box The screens that appear when these are chosen will be shown and explained in future slide

Page 1 – Choosing Search This is the most popular choice of buttons Program may be configured so that this option is required for all Transport/Patient calls Clicking will result in being taken to a Search for an existing Patient Helps avoid patients being entered several times into your system with different spellings, birthdates, etc. Saves time for “Frequent Flyer” calls by bringing up all information already on file Information may be changed as needed

Page 1 – Search Info Enter Patient Info as known % is our wild card, as shown here this would find patient if name entered as Kathy, Katherine, Kathleen, etc. Not all fields need be completed Click search button to perform search If Patient found, Patient information will be shown with 4 fields if completed If more than one is available you may choose If Patient not shown you may create new patient If Patient is shown choose their name to bring over all stored data

Page 1 – Patient Demographics Not all Fields MUST be completed Service may configure required Fields as desired Icon beside address will bring over address from referring location “Sex” field will drive fields in assessment area as to Obstetric field availability. Un-entered will assume male. “Age” field will control many features in assessments and treatments. Un-entered will assume “Adult”. Enter DOB will calculate age Save to continue

Page 1 – Patient Demographics Once saved additional Fields may appear Immunizations Employer Physician

Page 1 – Billing Information This section is for “Responsible Party” Information May enter multiple guarantors if needed No limit on this field area List all Insurance available in this section No limit to number of entries Area for Insurance numbers also Payor list may be pre-populated with most popular insurance companies if desired

Page 1 - PMHx Red Circle with line indicates NONE Red X allows you to delete incorrect choice Scroll Icon allows you to make entry into box May search by using mouse and choosing letters May begin typing to bring up choice May add free form for items not in existing list Most items already exist in choices Request to Add checkbox will send request to emsCharts to have non-existing item added to list This may or may not happen depending upon request May add unlimited # of entries “Obtained From” indicates who you received information from directly

Page 1 - Medications Medications simple list includes only name Extended Configuration will add fields for Dosage and Method These are for Medications they are taking at home Box works as prior boxes by either mouse or typing May request addition if desired May add Custom just to this chart if needed

Page 1 – Current Allergies Allergies listed by Name only May use mouse or type to narrow choices May enter by typing a Custom Entry May Request to Add also

Page 1 – Replace Patient On bottom of Patient Page Will return you to Patient Search To be used if the Patient you choose is not the correct Patient

Page 2 – PT,CC,HPI May not have top 4 fields, these are optional Chief Complaint box limited to 50 characters in NEMSIS states box indicates Spell Checker available. This must be clicked to run. will take entries from top four fields and write a chief complaint. Does nothing if top four fields are disabled CMS Condition is set list by Medicare. This is used by Billing. Complaint System

Page 2 – PT,CC,HPI Free form box Will hold 4000 characters (about 2 typed pages) May be used as a “Narrative” type field if so desired. (One of 2 areas recommended if “Narrative” is requested) History of Present Illness

Page 2 – PT,CC,HPI For Special Situations Additional Information Buttons For Special Situations Category of Call on Page 1 will determine which buttons may be available

Page 2 – PT,CC,HPI Important for Work Related Injuries Add’l Injury Details Important for Work Related Injuries Important for Falls May be needed if suspect intentional injury

Page 2 – PT,CC,HPI Who Witnessed CPR Information Defib Information Cardiac Arrest Who Witnessed CPR Information Defib Information

Page 2 – PT,CC,HPI All Fields are self-explanatory Drugs/Alcohol Motor Vehicle Incident All Fields are self-explanatory

Page 2 – PT,CC,HPI Exposure Button Details Scene Description is 4000 character field with spell checker Other EMS may be other trucks of your company or other services on scene Other Agencies will insert optional agency numbers if chosen Exposure Button Details

Page 2 – PT,CC,HPI Allows you to track all belongings patient may have with them at time of transport 4000 Characters with spell checker Allows you to check any forms you may be given at first facility and need to give to second facility. May not be needed for 911 services.

Page 2 – PT,CC,HPI These are all optional fields and may not appear on you charts Complete only if needed Simply check desired response as in example shown is Dispatch Factor

Are for Assessment Only!!! Pages 2 thru 7 Are for Assessment Only!!! If you perform a task of any type it is an ACTION and belongs on page 8! Actions listed in Comment Boxes will not be sent to your State and MAY NOT be picked up by your Billing Agency! This could result in loss of Revenue for your Company!

Page 3 – Neuro/Airway Will be completed with Defaults if available If patient is immobilized when you get there, the fields will appear as needed when field is changed to Yes Comment field for Neuro assessment,256 characters

Page 3 – Neuro/Airway GCS will auto calculate for you GCS will automatically adjust by age of the Patient If age is not entered it will assume they are an adult

Page 3 – Neuro/Airway Comments Field is 256 characters Defaults will enter any default values set by your Command Facility Cancel Changes will remove any changes just made

Page 4 – Resp. Cardio Respiratory Assessment Ventilator Button Optional Comments: 256 characters

Page 4 – Resp. Cardio Comment: 256 characters For Temperature be sure to set C or F first then enter actual temp. or it will calculate change

Page 5 – Secondary Survey Click on body part Complete box that will appear Save As many as desired Observe optional Buttons Obstetrics only available for Female Patients! You may want to be specific in your findings as NEMSIS does not always break down specific body parts!

Page 5 – Secondary Survey If the Anatomical Exam option is turned off you will have a chart to complete such as the one below. Obstetrics button will only be available for Female Patients

Page 6 – Labs, Fluids This page may be turned off if not needed! May be required for Critical Care transports!

Page 7 – Meds,IVs PTA Attention: These are PTA, meaning PRIOR TO ASSESSMENT! These are NOT what you do but what is already in place! The Add button will add the function completed and add a new line so an additional entry may be added if needed! These are optional fields and entry. This page may be turned off if not required!

Page 8 – Activity Log This is where you will enter EVERYTHING you DID! These are your actions during the call.

Page 8 – Activity Log Things to Remember Times from page 1 are listed at top of page for your reference Each item entered MUST have a time entered Every action entered will have a full 4000 character comment area with spell checker You may edit any action until chart is locked Entry will automatically go into correct order if entered out of sequence

Page 8 – Activity Log Vital Signs: Date will default to date of dispatch Time must be entered, but : not required between Complete all fields as needed Screen may vary by configuration settings Repeat Vital Sign Button will complete fields with last set of vitals No Change Button will enter “No change in patient status” in Comments box Click Add Line Button to complete Vital Sign Entry

Page 8 – Activity Log Time must still be completed! If Vital not done but another action is completed you will pull down the Add Action list to complete!

Page 8 – Activity Log All actions possible by EMS is included in these options Each Action will bring up a specific box for that Action Several options may be available under each Action Actions are determined by Level of Care listed on Page 1 in Dispatch

Page 8 – Activity Log Medication Fields Titrate Fields

Page 8 – Activity Log Intubation Fields Airway - Other Fields

Page 8 – Activity Log Initiate IV Fields Cardiac Fields

Page 8 – Activity Log Immobilization Fields Medical Consult Fields

Page 8 – Activity Log Labs Fields Drains Fields

Page 8 – Activity Log Note: CPAP is under Ventilator Log! Ventilator Fields Hosp. Notify Fields Note: CPAP is under Ventilator Log!

Page 8 – Activity Log To edit a set of Vitals you will highlight the left side of the activity log and the Vital will be highlighted in Yellow. Click to Open To edit an Action you will highlight the right side of the activity log and the Action will be highlighted in Blue. Click to Open

Page 8 – Activity Log NOTES: You may enter an Action at the same time as a Vital to save time if they are being performed simultaneously You do not have to enter a Vital Sign to use the Comments Box. This box will hold 4000 characters and can be used for any additional narrative you feel is needed. A time will be required as always. Multiple Comments may be used as required.

Page 8 – Activity Log Graphing your Call Clicking this button will create a graph of your Vital Signs for this call. This may be Printed by using the Print Button.

Page 9 – Misc Forms Page 9 is where you will complete and Lock your chart. This page may vary widely as many fields are optional by Service and State.

Page 9 – Attached Files The number of files attached will be indicated Any type of file may be attached Opening Attached Files Button will show you a list of attached File You will be allowed to upload any file you wish to save with this chart Files may be attached at any time by an authorized person Inserted Files become part of the Trip Record but are not part of the Chart!

Page 9 – Signatures This is where you will enter your electronic signature Click the Sign Chart button to open this box This must be the password to emsCharts and the SSN logged in your security settings The system automatically keeps a log of all signatures obtained

Page 9 – Print Chart This section allows you to print the Chart you just entered. Clicking on Chart will open the Chart in a new window and you will have the option to print the chart from there.

Page 9 – Print Chart Forms Button Chart & Forms Button Will print the forms located under Miscellaneous Forms Section. All Forms will print which have been chosen Chart & Forms Button Will print the forms located under Miscellaneous Forms Section as well as the chart.

Page 9 – Quality Assurance Charts not locked are considered Incomplete and will be indicated on your Home Page so you will not forget to complete them! This is Important! Each Chart must be locked to be complete Once locked the crew will not be able to make changes unless given permission to do so Once locked the chart will progress to the next “level” of QA as set by your company

Addendums may be added at any time to this Chart. Addendums become part of the Chart You will see the number of addendums added on the screen When you open the button you will be able to read all Addendums or enter a new one Adding Addendums may require a new chart be printed

Page 9 – Miscellaneous Forms The forms available will vary according to your service choices This is where you indicate which forms you wish to Print Required Forms Must be completed before a chart may be locked Optional forms do not have to be completed Any Special Reports filed on this chart will be able to be opened from this screen!

Page 9 – Custom Forms These are only available if emsCharts Mobile or PDA have been installed and signature forms have been obtained Clicking the View button will show all attached forms If you check the box then these forms will print with the Chart

Congratulations! You have completed the “Entering a Chart” Training Session. The next step should be trying to enter a Chart into emsCharts. It is only by practice that you will become proficient with the system. Once you begin entering trips you may wish to revisit this slide show to clarify certain sections.

emsCharts, Inc. 600 Mifflin Road Suite 102 Pittsburgh, PA 15207 866-647-8282 www.emsCharts.com Linda Coene Training Manager lcoene@emscharts.com Production Date: 07/30/2008 Property of emsCharts, Inc. Content may not be changed without written consent of emsCharts, Inc.