Transcript Entering a Chart - Allenhurst Fire Department

Entering a Chart
Using emsCharts Series # 1.4
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.
Page 1
This is page one of a chart entry. We will break this down into
various sections.
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.
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.
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
Page 1 – Crew Members
• Up to 4 crew members may be shown
• Letters in the front represent their Role.
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D = Driver
P = Primary
S = Secondary
T = Tertiary
O = Other
• Other people may be entered in the box below
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.
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!
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
Page 1 - Mileages
Out of County Miles
This box may be displayed if
required in your state
This does not calculate, but
would be entered manually
• 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
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
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
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
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
Page 1 – Search Info
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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
Page 1 – Patient Demographics
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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. Unentered 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
Page 1 – Patient Demographics
Page 1 – Patient Demographics
• Once saved additional
Fields may appear
– Immunizations
– Employer
– Physician
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 prepopulated with most popular
insurance companies if
desired
Page 1 - PMHx
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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 nonexisting 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
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
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
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
Page 2 – PT,CC,HPI
Complaint System
• 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.
Page 2 – PT,CC,HPI
History of Present Illness
• 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)
Page 2 – PT,CC,HPI
Additional Information Buttons
• For Special Situations
• Category of Call on
Page 1 will determine
which buttons may be
available
Page 2 – PT,CC,HPI
Add’l Injury Details
• Important for Work
Related Injuries
• Important for Falls
• May be needed if
suspect intentional
injury
Page 2 – PT,CC,HPI
Cardiac Arrest
• Who Witnessed
• CPR Information
• Defib Information
Page 2 – PT,CC,HPI
Drugs/Alcohol
Motor Vehicle Incident
• All Fields are self-explanatory
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
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.
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
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!
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
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
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
Page 4 – Resp. Cardio
• Respiratory Assessment
• Ventilator Button
Optional
• Comments: 256
characters
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
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!
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
Page 6 – Labs, Fluids
This page may be
turned off if not
needed!
May be required for
Critical Care
transports!
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!
Page 8 – Activity Log
This is where you will enter EVERYTHING you DID!
These are your actions during the call.
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
Page 8 – Activity Log
Vital Signs:
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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
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!
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
Page 8 – Activity Log
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Medication Fields
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Titrate Fields
Page 8 – Activity Log
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Intubation Fields
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Airway - Other Fields
Page 8 – Activity Log
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Initiate IV Fields
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Cardiac Fields
Page 8 – Activity Log
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Immobilization Fields
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Medical Consult Fields
Page 8 – Activity Log
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Labs Fields
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Drains Fields
Page 8 – Activity Log
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Ventilator Fields
Note: CPAP is under
Ventilator Log!
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Hosp. Notify Fields
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
Page 8 – Activity Log
NOTES:
1) You may enter an Action at the same time as a
Vital to save time if they are being performed
simultaneously
2) 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.
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.
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.
Page 9 – Attached Files
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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!
Page 9 – Signatures
This is where you will enter your
electronic signature
Click the Sign
Chart button to
open this box
The system automatically keeps a
log of all signatures obtained
This must be the
password to emsCharts
and the SSN logged in
your security settings
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.
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.
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
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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
Page 9 – Miscellaneous Forms
Any Special Reports filed on this
chart will be able to be opened
from this screen!
• 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
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
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.
emsCharts, Inc.
600 Mifflin Road
Suite 102
Pittsburgh, PA 15207
866-647-8282
www.emsCharts.com
Linda Coene
Training Manager
[email protected]
Production Date: 07/30/2008
Property of emsCharts, Inc.
Content may not be changed without written consent of emsCharts, Inc.