OutSmart EMR Knowledgebase

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Basic Charting

What is a Chart in OutSmart?

A Medical Chart, or SOAP Chart, in OutSmart are the notes taken during a single encounter with a patient.  A chart would be created every time your patient comes to see you.  All of these charts are stored in the Patient Workspace, which is like the patient’s folder in your clinic.  In some professions, a Medical chart may refer to your patient’s entire history, however in OutSmart, that is not the case.  A Chart refers only to the notes taken during a single encounter with the patient.

Creating a New Medical / SOAP Chart

A Medical chart, or SOAP chart, can be created in OutSmart from a number of different places.  A chart can be created from:

  • The SmartCharts page
  • The Calendar Event Editor
  • The Daily Schedule Card on the Dashboard
  • The Patient / Client Workspace

Creating a chart from the SmartCharts page

  • Go to the Main Navigation Menu, and select SmartCharts
  • On the Smart Charts page, select a patient form the drop down list.  This will load up a list of the patient’s previous charts.
  • Click on the Create New Chart button.
Creating a SOAP Chart from the SmartCharts page

Creating a SOAP Chart from the SmartCharts page

Creating a chart from the Event Editor

You can initiate the creation of a chart from the Event Editor in the calendar.  This is useful if you would like to move directly from your calendar to the charting interface.  It also helps to save a step when you create the chart because the system will not need to ask you which visit type is involved.  Since you are creating the chart from the Calendar Event Editor, then the system already knows the visit type involved.

  • Open the OutSmart Calendar, and click on an existing patient event.  This will open the Event Editor.
  • Check to ensure the event type and patient are correct, and then click on the ‘clipboard’ icon at the bottom of the Event Editor to create a new SOAP Chart.
Creating a new SOAP chart from the Calendar Event Editor

Creating a new SOAP chart from the Calendar Event Editor

Creating a chart from the Daily Schedule Card

Creating a SOAP chart from the Daily Schedule Card on the Dashboard is the easier and simplest way to create a chart.  The Daily Schedule Card is responsible for displaying all your appointments for the day, so it’s the logical place to go when checking your next appointments, and initiating the creation of a SOAP chart.

Creating a new SOAP chart from the Daily Schedule Card on the Dashboard

Creating a new SOAP chart from the Daily Schedule Card on the Dashboard

Creating a chart from the Client / Patient Workspace

If you prefer to get quickly caught up on your client’s file and notes before starting your chart, the Client Workspace is a good place to go.  Once you review your notes, you can create a new chart for the patient right from here.  Remember that in OutSmart, you are creating a new SOAP chart for every visit.

Creating a chart from the Client / Patient Workspace

Creating a chart from the Client / Patient Workspace

Introduction to the Charting Interface

The OutSmart charting interface puts all the most important tools and pertinent information right in front of you.  Your entire chart is managed from a single screen, and an index is automatically created as you go in order to help you navigate your chart and move from one section to another easily.

Medical Charting interface elements

Medical Charting interface elements

Chart Properties

The Chart Properties record the subject patient, the visit type, and the date and time of the visit.  All information in the chart properties can be changed, but note that these are also part of the audit trail, and every change is recorded.

Editing Chart Properties

You can edit the Chart Properties simply by clicking on them.  This will bring up the Chart Configuration panel.  The Chart Configuration panel will also show up anytime critical information about the chart is missing.  For example, if you create a chart from the Patient Workspace or the SmartCharts page, a Chart Configuration panel will appear asking you to specify the type of visit this will be.  If you create a chart from the Calendar or Daily Schedule card, then the Chart Configuration panel will not show up, because the system will already know the type of visit involved.

Chart Configuration Panel

Chart Configuration Panel

Chart Index

The Chart Index is a great tool to keep you anchored when charting.  It will automatically update with information about all the sections you add into the chart.  As you get familiar with charting, you will start using PRO sections which give you added functionality.  Since the entire charting experience takes place on a single screen, the Chart Index becomes an invaluable tool to navigate your chart to quickly add information to various sections.

The Chart Index can also be used to re-order the sections of your chart.  Just drag and drop any title or section in the Chart Index and drop it into a new order.  This will automatically update both the index, and the chart itself.

The SOAP Chart Index can be used to re-order sections, or to navigate your chart.

The SOAP Chart Index can be used to re-order sections, or to navigate your chart.

Chart Toolbar

The toolbar at the top of Medical chart connects you to other patient data, adjusts your charting view, and allows you to save and print.

The main toolbar of the SOAP charting system gives you access to a variety of functions:

Chart Histories

This Chart History button will give you access to show of hide the Persistent Chart History sections of the SOAP chart.

Show or hide Chart History sections

Show or hide Chart History sections

Save, Print, And Lock

The Print Treatment Plan button will generate a Patient Treatment Plan which you can then print to paper or to PDF.

The Print Chart button will generate a Full Chart print view, which you can then print to paper or to PDF.

The Save button will save a draft of your chart, and create an individual backup, in case you need to restore data at a later date.  Note that for audit purposes, the data you enter into your chart is time-stamped every 5 minutes.

The Lock button will digitally sign your chart.  You can still unlock the chart and edit as needed, the when you click on the lock button it essentially means that you have signed your chart, and it is a legal document now.

Print Treatment Plan, Print Chart, Save, and Lock buttons.

Print Treatment Plan, Print Chart, Save, and Lock buttons.

Additional Actions

The Additional Actions button opens up a list of other actions you can take, which includes viewing submitted SmartForms, previous charts, going to the Client Workspace, creating a new chart for the client, or deleting the current chart.  Note that charts are never permanently deleted.

More Options button

More Options button

Last Save Time

At the far right of the toolbar, you will also be able to see the last time the chart was saved.  The chart will auto-save every 2 minutes.

Last Save display, auto-saves and resets every 5 minutes.

Last Save display, auto-saves and resets every 5 minutes.

Chart Notes

The Chart Notes area of the charting interface is where you put your notes.  Depending on whether you are using Basic Charting or Pro Charting, and your own personal charting preferences, the Chart Notes area will vary in terms of what is presented on screen.  But in the end, this area of the interface is where all your medical notes will go.  You can learn more about the Basic Charting sections here.  When you are comfortable with the basic sections, you can then move on to PRO Charting.

Locking / Signing a Medical Chart

Clicking on the ‘lock’ button at the top of the Charting Interface is essentially the same as signing your chart.  It stamps the chart with a date and time for the signature, takes you out of the Charting Interface and back to your SmartCharts general page.  The chart is then also listed as locked in your chart list.  You can still unlock the chart if you want to make additions, however remember that the audit trail for your chart will reflect that changes were made after the chart was locked.

Unlocking a Medical Chart

To unlock your chart, simply click on the red  button in your chart list, and this will unlock the chart and allow you to continue editing.

Difference between a locked and unlocked chart in your chart list

Difference between a locked and unlocked chart in your chart list

Deleting a Medical Chart

There are several reasons why you might want to delete a SOAP chart, or any kind of medical chart you’ve created in OutSmart : a patient does not show up to the visit, you accidentally create a chart for the wrong person, etc.  Just keep in mind that our system never actually deletes anything – all deleted charts are archived in our database, and you can even restore them at a later date if they were deleted by accident.  Because of this, it is important to make sure that you delete charts in a manner that is consistent with the legal requirements of your profession.

Example 1: Deleting A Chart With Existing Information

Let’s say you created a SOAP chart for a patient and entered some preliminary information, but the patient did not show up for the visit.  You can either keep the chart there until the patient does show up and then continue the cart, or you may want to delete it.  If you are deleting a chart with existing information, it’s important to make a note in the chart about why you are deleting the chart.  Making a quick note like “Patient did not show up, deleting chart” is enough.  Then you can go ahead and delete the chart.

Example 2: Deleting A Chart Created By Accident, With No Existing Information

If you are simply deleting a chart created in error, and there is no information entered into it, then you do not need to leave a note,  just delete the chart.

Deleting The Chart

To delete the chart, you must open the chart in the Chart Editor, which is the page you go to when you are actively adding information to the chart.  You can access the editor by opening the chart from a Chart List.  Chart lists are available in the Patient Workspace or the Smart Charts page.  When you locate the chart you want to delete, open it in the editor by clicking on the Continue Editing Chart button in the right-most Actions column of the chart list.  This will open the editor.  Then click on the  More Actions icon in the Top Toolbar, and select Delete Chart.

Deleting a chart can only be done from within the charting interface.

Deleting a chart can only be done from within the charting interface.

Creating a Patient Treatment Plan

In the Basic Charting system, a Patient Treatment Plan is easily created by simply typing in your treatment plan in the Plan Freeform section of your chart.  Everything you enter into the Plan Freeform section will show up on the Patient Treatment Plan.  So the steps to creating a Patient Treatment Plan when using Basic Charting are:

  1. Enter or paste your treatment plan notes into the Plan Freeform section of the SOAP chart.
  2. Click on the “Print Treatment Plan” button at the top of the Chart Editing Interface.

This will generate a printable treatment plan for your patience which you can print to paper or save to PDF.

The treatment plan is entered into the Plan Freeform section of the chart, when using the Basic Charting method. Pro Charting offers more features.

The treatment plan is entered into the Plan Freeform section of the chart, when using the Basic Charting method. Pro Charting offers more features.

Printing Charts and Treatment Plans, or Saving to PDF

There are a few different locations from where you can print your Charts or Treatment Plans:

  • From the Chart Editor
  • From the chart list in the SmartCharts page
  • From the chart list in the Client/Patient Workspace
  • From the chart list in the Charts card on the Dashboard.

Printing from the Chart Editor

The Chart Editor is what is on screen when you are creating the chart.  This where you are actually typing in the patient’s medical information.  When you are on this screen, you can access the print view of this chart by clicking on one of the ‘print’ icons in the Top Toolbar of the chart.

Print the full chart or the Treatment Plan using the print buttons at the top of the Chart Editor.

Print the full chart or the Treatment Plan using the print buttons at the top of the Chart Editor.

Printing from the Chart List

Chart lists are displayed in various areas, like the Smart Charts page, the Patient Workspace, etc.  When you want to print a chart that you are seeing in a chart list, click on the  icon ‘Full Chart’ or the  icon ‘Patient Treatment Plan’ to open up the print view.

Print the Treatment Plan or the full chart from the chart lists on various pages.

Print the Treatment Plan or the full chart from the chart lists on various pages.

Once you have the print view open through one of the above methods, you can switch between the Patient Treatment Plan or the Full Chart by clicking the orange View Patient Plan or View Full Chart button at the top.

To print the chart you are viewing, click on the blue Print Chart button at the top right.  when you do this, it will open the Chrome Print Window, which will give you your printer options.

To print your Patient Treatment Plan, click on the Print Treatment Plan button at the top of the Charting Interface.  This will open up a print view of your treatment plan.  You can then click on the Print This Page button at the top right of the treatment plan, to open up the browsers printing dialog box.

From there, you can choose to print to a printer, or you can also print to PDF.  Printing to PDF will create a PDF file that you can save on your computer.

Print View of a Patient Treatment Plan. Click Print This Page to print the plan.

Print View of a Patient Treatment Plan. Click Print This Page to print the plan.

Google Chrome print dialog box. Your can print to a printer, or to PDF.

Google Chrome print dialog box. Your can print to a printer, or to PDF.

 

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