entering a chart using emscharts series # 1.4. entering a chart log into emscharts from your home...

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.

This is page one of a chart entry. We will break this down into various sections.

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.

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.

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

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

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.

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!

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

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

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

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

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

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

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

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

Patient Demographics

• Once saved additional Fields may appear– Immunizations– Employer– Physician

Page 1 – Patient Demographics

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

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

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

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

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

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

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

PT,CC,HPI

• For Special Situations• Category of Call on

Page 1 will determine which buttons may be available

Additional Information Buttons

PT,CC,HPI

• Important for Work Related Injuries

• Important for Falls• May be needed if

suspect intentional injury

Add’l Injury Details

• Who Witnessed• CPR Information• Defib Information

Cardiac Arrest

Page 2 – PT,CC,HPI

PT,CC,HPI

• All Fields are self-explanatory

Drugs/Alcohol

Motor Vehicle Incident

PT,CC,HPI

Exposure Button Details

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

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.

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!

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

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

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

Resp. Cardio

• Respiratory Assessment• Ventilator Button

Optional• Comments: 256

characters

Resp. Cardio

• Comment: 256 characters• For Temperature be sure to set C or

F first then enter actual temp. or it will calculate change

Secondary Survey

• Click on body part• Complete box that

will appear• Save• As many as desired

You may want to be specific in your findings as NEMSIS does not always break down specific body parts!

Observe optional Buttons

Obstetrics only available for Female Patients!

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

Labs, Fluids

May be required for Critical Care transports!

This page may be turned off if not needed!

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!

Activity Log

This is where you will enter EVERYTHING you DID! These are your actions during the call.

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

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

Activity Log

If Vital not done but another action is completed you will pull down the Add Action list to complete!

Time must still be completed!

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

Activity Log

• Medication Fields • Titrate Fields

Activity Log

• Intubation Fields • Airway - Other Fields

Activity Log

• Initiate IV Fields • Cardiac Fields

Activity Log

• Medical Consult Fields• Immobilization Fields

Activity Log

• Labs Fields • Drains Fields

Activity Log

• Ventilator Fields • Hosp. Notify Fields

Note: CPAP is under Ventilator Log!

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

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.

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.

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.

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!

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

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.

Print Chart

Forms ButtonWill print the forms

located under Miscellaneous Forms Section.

All Forms will print which have been chosen

Chart & Forms ButtonWill print the forms

located under Miscellaneous Forms Section as well as the chart.

Quality Assurance

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

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!

• 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

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!

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] Date: 07/30/2008

Property of emsCharts, Inc.

Content may not be changed without written consent of emsCharts, Inc.

http://www.emscharts.com/

entering a chart using emscharts series # 1.4. entering a chart log into emscharts from your home...

Documents

home page

new page

different page

configurable slide

new chart

chart entry

configuration settings

blank chart