Use Chart Part templates to add any combination of text to the text of your SOAP note and/or suggested actions (diagnoses, prescriptions, orders, supplements, charges, even handouts) to a note simply by typing the name or nickname of the Chart Part into the main text area and selecting the desired Chart Part from the suggestions that appear to the left of the note.
This feature can be used to auto-complete a commonly-used phrase, add a set of text prompts, add a combination of actions (like a lab panel), or add any combination of text and actions to the note.
Creating Your Chart Parts
Create or manage Chart Parts via the Admin drop down menu at the top of the page. Select Manage... >> Chart Parts, then click on +Add New to create your own or click on an existing Chart Part to edit it.
- Name, and nicknames - this is how you will search for the Chart Part. A name or nickname may not contain spaces or any of the following special characters: \ ^ % & *. Multiple nicknames should be separated by spaces.
- The scope of the Chart Part refers to who may use it: just the user who creates it or anyone in the practice.
- Add text that you want to appear exactly as written when the Chart Part is called and/or text variables (see below) to pull context specific information from the patient's chart.
- Add a diagnosis, drug, order/lab, vaccine, charge or alternate plan option (supplements, recommendations, etc.) by first selecting the type of action to add using the Add Action drop down menu, searching for the desired entry using the search bar to the right, and then selecting an action to add it to the Chart Part. Remove any action that you've already added by clicking the [x] to its far right.
When finished, click +Add New Chart Part.
In addition to static text, Chart Parts can contain text variables, which will add patient- or encounter-specific information (such as the patient's date of birth, most recent vitals readings, past diagnoses, current preferred pharmacy, etc.) to the text of the note when the Chart Part is used, rather than appearing exactly as typed.
Variable names are enclosed in double brackets, as in: [[variable]] and, when the Chart Part is used, the bracketed text is replaced with the specified information. So, for example, a Chart Part that included the following text: "[[pt_name]]'s date of birth is [[pt_dob]]" would appear in the text of a note for John Doe as "John Doe's date of birth is 11/20/1981". You can view and select from available variables by clicking on List available variables on the right-hand side of the Add New Chart Part pop up.
If your EHR build has been configured to use custom vitals or lab-values in the Vitals block, you can use special variables for recalling those values in a chart part using the following syntax:
[[pt_vital_ShortNameOfVital]] or [[pt_vital_IdOfValue]]
So if you regularly record a patient's PulseOx reading, you can pull up the last value in a SOAP note using the variable [[pt_vital_PulseOx]] in a chart part. If you know the ID of the custom variable (you might need to ask your MD HQ administrator for this) you could also use the ID syntax: [[pt_vital_317]] (note: this is for demonstration only - 317 is not necessarily the ID for a PulseOx reading).
Using Chart Parts
A Chart Part is accessed and added to a note by typing all or part of its name or nickname in the main text field of the open encounter note (or another free text field that supports this feature, such as email notifications and reminders in the Calendar). Matches will appear to the left as you type. Click on one to select it. To select an entry from the list without using the mouse, press the up arrow to select and add the topmost entry or toggle to the list by pressing the left, right, or down arrows on the keyboard. Within the list, the down (or right) arrow moves down the list, and the up (or left) arrow moves up. Press enter to select.
Once selected, any text from the Chart Part template will be added to the main text block (or to the applicable free text field). In an encounter note, actions will be added as "Suggested Actions" above the yellow Assessment block on the right. Click on a suggested action to add it to the note. Click on the x to the right of any suggestion to remove it.