Creating a New Chart Note
1. Once you've located the desired patient record, and they are actively displayed within the Patient Reserve, select the Charts widget which can be found on the Choose Action, Patient Screen, or Scheduler Quicklinks.
2. Select the (+) in the upper right corner of the screen, select the desired chart note type, and assigned seen by provider. Then select Ok to open.
Documenting Patient Vitals & History
1. In the VS section at the top, type the patient's vital information. The weight will update in the Patient Reserve automatically once entered.
2. CC stands for Chief Complaint, and it's recommended to document the reasoning for the visit. Example: Vomiting, Annual Vaccines, Losing Weight, etc.
3. If using a SOAP note format, the ROS section (Review of Systems) allows Veterinarians to identify a patient's body systems that are either within normal limits (selected) or abnormal (unselected).
4. If using a SOAP note format, the (S) field stands for Subjective, and this is where patient history is captured in most practice settings. Alternatively, if using any of the other Chart types, you'll type the patient history in the Notes field. You can free-type the patient history, or use chart templates that live along the right side of the screen. For more information on using Chart Templates, check out Choose Action: Creating and Editing Chart Templates.
The system will autosave, however, it's always encouraged as an added precaution to select Apply in the lower left corner of the screen before exiting the chart note.
Once the appointment documentation and findings have been added, the Chart Note can be finalized by Veterinarians. For more information, check out Choose Action: Finalizing Chart Notes & Medications.