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Entering a Chart

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Entering a Chart Using emsCharts Series # 1.4 – PowerPoint PPT presentation

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Title: Entering a Chart


1
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 IDs 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
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
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
Addl Injury Details
  • Important for Work Related Injuries
  • Important for Falls
  • May be needed if suspect intentional injury

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

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

30
Page 2 PT,CC,HPI
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
  • 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
  • Medical Consult Fields
  • Immobilization Fields

52
Page 8 Activity Log
  • Labs Fields
  • Drains Fields

53
Page 8 Activity 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
  • 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
  • 866-647-8282
  • www.emsCharts.com

Linda Coene Training Manager lcoene_at_emscharts.com
Production Date 07/30/2008
Property of emsCharts, Inc. Content may not be
changed without written consent of emsCharts, Inc.
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