Medical Charting.com Spring Charts Easy to Use, Full Function, Affordable
Medical Charting.com Spring Charts
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Working With Patient Charts
Click for a view of a Patient Chart.
The Patient Chart is composed of a Care Tree on the right side listing encounters (progress notes), tests and other records and a series of panels on the left for recording and editing persistent patient information such as Allergies, Problem List, PMHX, etc.To edit information on the left side panels, click on the label, or use the Edit menu.
To Edit an encounter, open the Care Tree to the encounter you wish to edit, click on the encounter and select the Edit button. To enter a new Encounter, select the New menu and click on the type of encounter you wish to add. The most common encounter is the office visit. Create a new office visit by selecting the New menu and clicking New OV. Depending on the user preferences, the following new office visit screen (New OV Classic view in this example)*** appears.
***for details on the new New OV Large view, click here.
The New OV editing screen is divided into four sections: S (Subjective), O (Objective), A (Assessment), and P (Plan).
Enter S notes by typing, dictating or using the PopUp Text (the small red button ) to make an entry into the text field.
Enter O notes by entering the appropriate vital signs and typing, dictating or using the PopUp Text to make an entry into the text field.
Enter A by using the Dx button to select Diagnoses and using the text field for DX or discussion.
Enter P by Selecting prescriptions using the Rx button; use the printer icon button under the Rx button to print Prescriptions. Order labs and other tests using the Test button; use the printer icon button under the Test button to print an order for these tests, order procedures using the Procedure button. Procedures can be classified within SpringCharts such as immunizations, injected meds, minor surgery, and other user-chosen categories.
Enter Other treatment in the text field.
Enter follow-up using the F/U field. Use the reminder button () to add a reminder about this patient to your ToDo/Reminder list.
The bottom buttons are:
Done - saves the Office Visit and closes the window.
Edit - enter the edit mode.
Print - prints the office visit.
Report - creates a printable/email document which includes the examination and lab results (if completed).
Delete - deletes this office visit.
H&P - creates a History and Physical (H&P) form using data from this office visit and the information in the chart (Allergies, Medications, PMHX, etc).
Draw - draw a picture to include with this office visit or import a picture and draw on it (annotate) for permanent documentation.
Template - use a user-defined template to enter this office visit.
Spell - used to spell check the chart.
Pt Instr - used to create instructions for the patient.
Sign - signs and locks this office visit.
Change Tab - used to change the tab where the visit is displayed on the right side.
The other encounter types under the New menu: Nurse Note, Note, TC Note, Rx Refill, and Vitals Only are subsets of the New OV note above and have similar functionality. One other encounter type is the Message. Messages are entered from the messaging system only; they cannot be modified once entered into the chart.
Patient Chart menus
File menu
Find Text - searches the entire chart for a matching word. To search all charts, use the Search feature on the Main Window.
Evaluate Chart - checks this patient for criteria set up by the user on SpringChartsServer. These criteria can be very flexible. This can be a powerful tool for preventative medicine.
Export Chart - allows you to generate a plain text copy of the Patient Chart for printing.
Print Chart - allows you to print all or parts of the chart.
Close Chart - closes the chart.
Lock Chart - prevents any user from viewing this chart other than the user who locks the chart.
Change View - allows the user to view the Care Tree in full detail, abbreviated form, or brief form.
Edit menu
Allergies allows editing drug allergies and other sensitivities.
PMHX allows editing of past medical history.
FMHX allows editing of family medical history.
Medications allows entering and editing of the patient's routine medications and OTC meds.
Immunization allows entering patient's past immunizations. Any new immunizations are automatically entered for you.
Problem List allows editing of the problem list. Entries can be either diagnosis or text.
Social Hx allows editing social history. a checklist is provided for rapid entry. The checklist is defined on SpringChartsServer.
Chart Note is a location for entering information about a patient which is not an encounter -- it replaces sticky notes.
Referring Dr allows setting and editing the referring doctor - you choose the doctor from your address book.
Set Default Pharmacy allows editing the patient's routine (default) pharmacy.
Delete Default Pharmacy allows you to delete the default pharmacy.
Edit Pt Photo allows setting the patient's photograph in the chart.
Window menu
The Windows menu lists all currently open screens.
Actions menu
Lab allows entry of lab tests which were not ordered from SpringCharts and viewing lab test results over time.
Diagnosis List allows viewing of all diagnosis.
Immunization allows entering patient's past immunizations. Any new immunizations are automatically entered for you.
Medications List allows viewing all medications prescribed.
Procedures List allows viewing of all procedures.
Imaging allows entry of Imaging tests not ordered through SpringCharts.
Graph Vital Signs allows viewing BP, height and weight data as a graph. For children, data is viewed as a standard growth chart.
Med Tests allows entry of other medical tests not ordered through SpringCharts.
New menu
New OV creates a new office visit which is filed in the tree under Encounters.
New Note creates a blank note which is filed in the tree under Encounters.
New Nurse Note creates a new nursing note which is filed in the tree under Encounters.
New Rx Refill creates a new medication refill form which is filed in the tree under Encounters.
New TC note creates a new telephone encounter form which is filed in the tree under Encounters.
New Vitals Only creates a new vitals form which is filed in the tree under Encounters.
New Letter to Pt creates a new letter addressed to the patient which is filed in the tree under Encounters.
New Letter ABOUT Pt creates a new letter concerning the patient. Recipient name and address information can be easily retrieved from the Address Book.
Import a Graphic provides for the import of pictures and other graphic data in *GIF or *JPEG format into the chart. Imported graphics are filed in the tree under Encounters.
New Test Report creates a blank test reporting form. Completed tests for this patient can be added from a PopUp Text list.
New Excuse/Note/Order provides for the creation of printable forms for work/school excuses, notes or orders.
Flow Sheets allows the creation of a simple document for repeated use. Commonly used for tracking diabetes results, allergy injections, etc. Once a Flow Sheet is created, it appears in the tree from which is can be later modified.
Import Text File allows the import of a text file into the patient's chart. Commonly used to import previous records.
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