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

2. 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.

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

4. 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.

5. 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.

6. 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

7. 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

8. 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.

9. 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!

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

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

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

30. 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

31. 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.

32. 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

33. 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!

34. 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

35. 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

36. 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

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

38. 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

39. 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!

40. 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

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

42. 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!

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

44. 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

45. 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

46. 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!

47. 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

48. Page 8 – Activity Log
Medication Fields
Titrate Fields

49. Page 8 – Activity Log
Intubation Fields
Airway - Other Fields

50. Page 8 – Activity Log
Initiate IV Fields
Cardiac Fields

51. Page 8 – Activity Log
Immobilization Fields
Medical Consult Fields

52. Page 8 – Activity Log
Labs Fields
Drains Fields

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

54. 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

55. 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.

56. 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.

57. 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.

58. 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!

59. 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

60. 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.

61. 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.

62. 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

63. 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

64. 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!

65. 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

66. 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.

67. emsCharts, Inc. 600 Mifflin Road Suite 102 Pittsburgh, PA 15207
Linda Coene
Training Manager
Production Date: 07/30/2008
Property of emsCharts, Inc.
Content may not be changed without written consent of emsCharts, Inc.