Clinical Charting. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

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1 Clinical Charting This guide explains basic clinical charting functionality. Additional guides and training videos provide more in depth discussion. Consolo endeavors to keep these guides up to date, but you should routinely review Release Notes (under the Help Menu) to stay abreast of any updates to functionality. Documenting patient care in Consolo is accomplished via Clinical Charting. A specific entry into the patient s medical record is called simply a clinical chart. Clinical charts are created to document assessments (nursing, social work, chaplain, bereavement), visit notes, physician orders, hospice aide visits, supervisory visits, face to face visits, fall, wound, and pain assessments, explanation of services, teaching and learning activity, inpatient unit activity, and miscellaneous patient-related activity. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

2 Creating a Chart Entry There are several ways to begin creating a clinical chart entry: Click the New Button on your Upcoming Visits Dashboard: Click the Create a New Clinical Chart button on your Scheduled Visits Dashboard: Consolo Clinical Charting Entry Basic Functionality Feb P a g e

3 From the patient s homepage, click the + next to Clinical Charts: From the patient s Clinical Charts summary screen, click Create a new Clinical Chart under Related Links: Consolo Clinical Charting Entry Basic Functionality Feb P a g e

4 Completing a Clinical Chart Entry The Clinical Chart entry form looks like this: Menu The column on the left side of the screen lists all of the available charting elements Chart Entry Area The largest portion of the screen, to the right of the menu, is reserved for displaying the currently selected charting element. In the example above, General Clinical Chart is selected in the menu; the General Clinical Chart form is displayed to the right of it. Related Links Click to access various clinical scales for reference. To begin charting, select the desired elements from the left side menu. There are three sections of menu options: Common Sections These are the most frequently used items, and will be utilized in a majority of charting situations. Click to select and complete a section. Selected Sections Items you ve selected. These sections will be included in your final/saved chart entry. Available Sections Items that you have not selected, but could select if desired. NOTE: Available sections are determined by the User s Role. Once all desired sections have been completed, choose from the following options at the bottom of the clinical chart entry form: Save as Draft Saves your chart entry locally, in your web browser, for later completion Visible only to you. Create Saves your chart entry in Consolo itself, visible to other users. Once Created, you ll have the option to create follow up Tasks (covered in a separate Guide) and add your Electronic Signature. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

5 Functionality Common to All Chart Sections These functions and features are available throughout the clinical charting interface. Selected Sections indicated by check mark. Clicking on a section will include it in your finished chart entry. You can tell which sections you ve selected by noting which ones have a check mark next to them: Section Enabled / Reset. If you click on a section inadvertently, you can remove it from your chart entry by clicking the red Reset button. You can also use the Reset button to clear all of your data from that section, if you want to start over. Once a section has been Reset, it is no longer part of the chart entry. To include it in the chart entry, click the Enable button to re-activate it and include it in the chart entry: View. To view the contents of a chart section completed at a previous time, click the View button. For example, if I m charting a Nursing Summary on Wednesday, I can see what the Nursing Summary from last Friday said by clicking the View button. This allows you to review the previous visit s information without leaving the current screen: NOTE: The Clone button will actually copy the contents of the previous entry into the current one. This feature can be disabled in Admin/Roles. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

6 Common Sections First, address Common Sections. These sections are used in most chart entries. General Chart Details. This section is part of EVERY clinical chart entry: Effective Date, Discipline, and Chart Owner These default to Today, your default Discipline, and your name, respectively. Click in any field to change if necessary. Visit Frequencies for Today This table displays current visit frequencies as a reference. This allows you to double check that you re in compliance with the patient s visit frequency. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

7 Patient Time Patient Time is NOT a required chart element, however, you should include it if you want to track the time spent on the activity being charted. Date In/Out Defaults to today. They will almost always be the same. The only time Date Out will differ from Date In is if the activity being charted crossed over midnight. In other words, Date In/Out will always be the same, unless the activity literally began on one day and ended on another. Time In/Out The actual time the activity began and ended. For patient visits, this is the actual time spent visiting the patient. Date & Time information are required (shaded in blue) fields: If you select the Patient Time form, you must include Date/Time information. Comments Optional comments regarding the Patient Time form Clinical Care Type Select an appropriate category for this Patient Time, based on instructions from your hospice Mileage Mileage to this activity Travel Start/Stop Record the travel time to this activity Out of Pocket Expense Consolo Clinical Charting Entry Basic Functionality Feb P a g e

8 Electronic Visit Verification (EVV) This section is not required if the activity being charted is not a patient visit. For patient visits, your agency will tell you whether or not to use this section. Electronic Visit Verification must be completed AT THE TIME AND LOCATION of the visit. It CANNOT be completed at a later time or different location. EVV is a method of verifying that you were at the patient s location, using either or both of these methods: o Geolocation Click the Find Geolocation button to utilize your device s internet connection, 3G/4G connection, or GPS to plot your location on a map. Click Show Location on Map to verify that your location was properly recorded. Note: you must allow your web browser to track your location in order to use this function. o Signature Pad The patient, their caregiver, a family member, or facility staff person may physically sign the Signature Pad to verify that you were at the patient s location. Use your device s touch screen, mouse, or electronic pen device to complete this action. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

9 Care Plan Problems See the Care Plan Problems Guide for instructions Use this section to document any care plan related activity you performed This section is not required, but should be used in conjunction with any actual patient visits Consolo Clinical Charting Entry Basic Functionality Feb P a g e

10 Other Sections Once you ve addressed the Common Chart sections, choose all the other chart sections that you d like to address. Click on each item you d like to address in the left side menu, and those sections will list in your Selected Sections list. In this example, Vital Signs and Nursing Summary have been selected: Follow these guidelines to complete your chart entry: Complete all the necessary fields in each chart section. When printed or faxed, only fields that contain user-entered data will be displayed. Only save (Create) once. You do not need to click the Create button after each section. Any fields shaded in blue are required, and must be completed in order to save your chart entry. Some sections can be added multiple times to the same entry, because there may be multiple items to chart: o Bereavement Assessment add once for each individual family member assessed o Fall Event add once for each Fall event documented at this time o Pain Observation add once for each Pain Site being assessed o Wound Assessment add once for each Wound Site being assessed Review or update any selected sections by clicking them on the left side menu. When finished, click Create. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

11 Completing a Chart Entry When finished with your chart entry, select one of the following options: Save as Draft Choose this option if you re not ready to submit your chart entry to Consolo. A copy of your incomplete chart entry is saved locally in your computer s web browser. You may close your computer, or power it down. Do NOT clear your browser s cache, clear offline content, or un-install your web browser. Your drafts will only be visible to you, and ONLY on the computer on which they were created. Drafts are NOT saved in Consolo, and if lost, are not recoverable by Consolo. Drafts do not affect time sheets, IDG or any other report, visit frequencies, dashboard alerts, etc. Continue editing resume working on your clinical chart entry Close chart close this web browser tab. See my drafts see a list of all your drafts. Return to patient go to patient s homepage. When you re ready to complete your draft, you may find it using either of these methods: Patients Menu / Clinical Charts: Patient s homepage / Clinical Charts: Consolo Clinical Charting Entry Basic Functionality Feb P a g e

12 Click the Would You Like to Finish Them? button to see a list of available drafts: Delete all to permanently and irretrievably destroy all drafts. Edit icon to resume work on this draft Trash can icon to permanently and irretrievably destroy a single draft When the edit icon is selected, the chart entry in question re-opens. Complete your chart entry. Create Chart Entry Choose this option when you re completely finished creating your chart entry. Once the create button is clicked, the chart entry becomes a permanent part of Consolo. After clicking the Create button, address the following: Error messages if a chart entry is missing information in a required (shaded blue) field, you ll get an error message. The chart section and field that are missing will be highlighted in red. Correct the error(s) and click Create again: Consolo Clinical Charting Entry Basic Functionality Feb P a g e

13 Once your chart entry is created, Consolo will offer the option of creating Tasks. See the Tasks guide for information. Create as many Tasks as desired. When finished, click the X, or click anywhere outside the Tasks box, to continue: Next, Consolo will ask if you want to electronically sign your chart entry. You may sign later if not prepared to sign yet. Once signed, chart entries are NOT editable by ANY user. Ultimately, all chart entries should be signed. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

14 Addendums and Voids Once a clinical chart entry has been created and signed, it may not be edited. You may, however, add an Addendum or Void the chart entry. Addendums While viewing a clinical chart entry, click Related Links, then Create Addendum. Addendums are a useful way of adding a minor change to a signed chart entry: The Addendum form looks like this: Addendum Reason Required. Identify if you re Adding Information, Correcting Information, or charted on the Wrong Patient. Clinical Chart Section Optional. Identify the affected chart section (e.g. Vitals ). Note Required. Add or correct the necessary information here. Once created, the addendum is permanently attached to the clinical chart entry, beneath the signature: Consolo Clinical Charting Entry Basic Functionality Feb P a g e

15 Voiding Clinical chart entries may also be Voided. This is a soft delete. In other words, the chart entry is removed from the patient s active medical record, and from the user s timesheet. It will also have no impact on IDG reports, other reports, visit frequencies, etc. Voided charts are permanently stored in Consolo however, and may be reviewed, or recovered and returned to the active medical record. See the Voiding Clinical Charts guide for more info. Other Clinical Charts Functionality Related Links When viewing a chart entry, Related Links offers the following options: Add your Signature If not already e-signed. Add Physician Signature If applicable, e.g. for a physician order. Print/PDF Convert the chart entry to a printable/downloadable format. Edit this Clinical Chart only if chart is NOT signed. Create a new Clinical Chart Create another chart entry for the same patient. Fax Chart Fax this chart entry. See Faxing guide for more information. Void Chart See description above. Clinical Charts Global and Patient Specific Summary Screens From a patient s homepage, click on Clinical Charts to see a summary of that patient s clinical charting. From the Patients Menu, in the menu bar across the top of Consolo, select Clinical Charts to see a GLOBAL summary of charting for ALL patients. The two screens look and function the same. The difference is that the Clinical Charts screen accessed via the patient s homepage is specific to just that patient. The Clinical Charts screen accessed from the Patients menu is a global screen showing charting for all patients. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

16 The Clinical Charts Summary screen has a set of Filter Options at the top. These filter options are used to search for clinical charts that meet the specified criteria: Date Range Charts created within the Date Range Office Charts for patients assigned to a specific Office Patient Charts for the specified patient Discipline Charts created by the specified discipline Team Charts created for patients belonging to the specified Team Chart Owner Charts owned by a specific User Created by Charts created by a specific User. Creator and Owner will almost always be the same. The exception is if one person charted on behalf of another. For example, a MD dictated to an RN, who created a chart entry. The Owner is the MD; the Creator is the RN Has Signature, Has Physician Signature, Has EVV, Has Patient Time Returns only charts that match the specified Signature, EVV, or Patient Time status Clinical Chart Types Returns only charts that include the specified section(s). Hold the CTRL key on your keyboard to select multiple sections. Example: Date Range = July 2013 Has Physician Signature = No Clinical Chart Types = Physician Order Click Filter Button Returns a list of all unsigned physician orders from July 2013 NOTE: Use the Toggle button to hide the filters; use the Reset button to clear the filters. Consolo Clinical Charting Entry Basic Functionality Feb P a g e

17 Beneath the filter options is the list of clinical charts. They are always displayed with the most recent entry on top: Patient Column Name of patient; click to view patient homepage Effective Date Effective date of the chart entry Discipline Discipline, or Role, of the User who owns the entry Chart owner Name of User who owns the entry. Click User name to send an with link to the specified chart entry Created by - Name of User who created the entry. Click User name to send an with link to the specified chart entry Office Name of patient s Office Team Name of patient s Team, if any Completed Sections lists all the sections contained within the chart entry Signed, Has EVV, Time Units - Is the chart entry signed? Does it have EVV information? How many time units? A time unit (from the Patient Time section of the chart entry) is 15 minutes Eyeball Icon Click to View the chart entry Print Icon Click to Print the chart entry Edit Icon Click to edit the chart entry. If a padlock appears instead, the User may not edit the chart entry, either because it is signed & locked, or because they don t have Role Permission to edit it Trash Can Icon Click to Void the chart entry Check box To print multiple chart entries, place a check next to each entry to be printed. Then, under Related Links, choose Printed Selected Charts Legend Some chart entries will display an icon in the Completed Sections column: o Flag Tagged as Comprehensive this chart entry is the patient s comprehensive nursing assessment o Tag Chart has Addendum an addendum was added to this signed entry o Clock Countable Visit chart entry counts as a visit because it has patient time, and either (b) includes any chart section except for Visit Note, or (c) includes Visit Note with a countable (asterisked) Visit Type o Silhouette Nursing Visit a countable visit performed by a User whose discipline is RN or Skilled Nurse. Consolo Clinical Charting Entry Basic Functionality Feb P a g e