Transcript Medilinks Guided Practice

Guided Practice Exercises
Systems Training
Charting
October 2009
1
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Charting
A
Add charting For Acute Care Only
A. Treatment Screen
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1. Open the Treatment Screen
2. Right-Click the patient listing and select CHART TX or
click the patient listing once and select CHART TX icon at
the top of the screen
 NOTE: Always make sure that you have selected
the correct patient before adding the chart note.
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Find a Patient
B
Daily Schedule pane –
Choose a patient (For
Out Patient only)
B. Daily Schedule Pane
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1
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1. Right-click on a
scheduled appointment
To chart a treatment for the
patient, select CHART
To edit the scheduled
appointment, click EDIT
To cancel the appointment,
click CANCEL
To view the patient and
his/her information on the
main MediLinks screen,
click SELECT PATIENT
To print the details of the
scheduled appointment,
click PRINT
APPOINTMENT
 NOTE: This capability is
only available to users
who have appointments
scheduled
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Charting
C
Add charting
C. Patient Find (For Rehab only)
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1. Search for patient
2. Right-Click the patient listing and select ADD CHARTING
 NOTE: Always make sure that you have selected
the correct patient before adding the chart note.
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Charting
D
Add charting
D. Patient Charting tab
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NOTE: The patient must be in context
1. Click the ADD CHARTING icon on the
patient’s Charting tab
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Charting
1
3
2
Add a template – NEW TEMPLATE icon
In the Charting Entry screen:
 1. Click the NEW TEMPLATE icon
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RESULT: Template Selection window appears
 2. Click on the desired template to highlight it

If needed, sort and group to identify the desired template
 3. Click the OK icon to open the desired template

If you double-click the desired template, it will open for use
 NOTE: The Template Selection window will appear
automatically if the following conditions are met:
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TEMPLATE CHARTING is set as the DEFAULT CHARTING
START PAGE in your User Configuration screen settings
No template favorites are configured
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Charting
1
3 2
Configure favorites
In the Charting Entry screen:
 1. Click the FAVORITES icon
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NOTE: Favorites need to be configured per facility.
 2. Select a row and click the ADD icon
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Select the desired template to highlight it and click OK to add it
or
Double-click the desired template to add it
 3. Click the USE icon to open the desired template
 NOTE: In the future, you only need to press [ALT]+[#]
on the keyboard to open your “favorite” template – up to
ten (10) favorites are allowed
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Charting
1
2
Initiate documentation
To begin documenting the note:
 1. Check the AUTO-RUN TEMPLATE check box
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RESULT: The first available charting object (branch code) will
display for documentation
NOTE: With this checked, the template will automatically advance
you in order through each consecutive branch code until all of the
branching objects are resolved
OR
 2. Double-click on the desired “Branch” entry object
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RESULT: The selected branch code will display for documentation
NOTE: Once the branch code has been completed, the template
will wait for you to choose (double-click) the next branch to
complete until all the branching objects are resolved. This
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approach allows you to document in the order that you choose.
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Charting
1
2
Branching logic codes – data entry
There are two types of branching logic codes:
 1. Text Entry – text and numeric responses
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A. Use the keyboard to enter the text and/or numeric characters
B. Click the OK button with the mouse or press the [ENTER] key
on the keyboard to proceed to the next branch code
OR
 2. Selection List – selected responses from preset lists
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A. Mouse: Click the desired item, then click the SELECT button
B. Mouse: Double-click the desired item – advances you to the next
branch
C. Keyboard: Press the arrow keys to select the desired item, then 9
press the [ENTER] key to proceed to the next branch code
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Charting
Entry Screen
Enter data here
1
2
3
Preview
Do not type or
edit in this
screen!
Branching logic codes – interaction with the screen
 1. CANCEL icon – exits current branching logic
sequence
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Use to exit the branch without documenting (e.g., selected the
wrong branch by mistake or if you are not yet ready to document)
NOTE: Canceling the branch does not retain the documentation but
it does allows you to start the branch over at another time
 2. INTERRUPT icon – exits the entire chart note
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Use to save an incomplete chart note
NOTE: If the interruption occurs during the branching logic
sequence, the documentation from that sequence is not saved
NOTE: Interrupting the branch allows you to start the branch over
at another time
 3. ERASER icon – backtracks in the current sequence in
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order to change a previous entry
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Charting
2
3
Free-Text
Place your cursor in the
body of the template and
type additional notes
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Free-text documentation
 1. Place the cursor where you want to add free-text
documentation


Any text that is typed as free-text will not be captured in
observations (memory) for use in other places (e.g., the Care Plan
flowsheet); it will only remain in this chart note
NOTE: Do not fix branching code mistakes with free-text without
fixing your observation entry as well. Otherwise, your changes will
not be captured appropriately
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Charting
Insert a Mini-Template
Place your cursor in the template and insert the “mini”
2B
2A
3
1
Add a mini-template to a chart note
Begin with an open charting template
 1. Place the cursor where you want to insert the minitemplate

Can be in the body of the charting document or at the beginning or
the end of the chart note
 2. Insert the mini-template

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A. If the desired mini-template is a favorite, press [ALT]+[#] on the
keyboard or click the FAVORITES icon
B. Click the NEW TEMPLATE icon and select the desired minitemplate from the Template Selection window
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 3. Document on the mini-template
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Charting
1
2A
To delete a mini-template from a chart note
 1. Highlight all of the text and entry objects from the
inserted (and unwanted) mini-template
 2. Delete the highlighted mini-template and text
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A. Right-click with the mouse and select DELETE
B. Press the [DELETE] key on the keyboard
C. Press the [BACKSPACE] key on the keyboard
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Charting
1
Interrupt a chart note – 1
 1. Click the INTERRUPT icon at the top of the screen
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NOTE: This icon is available only if the branching logic Data Entry
screen is closed
NOTE: A chart note can be interrupted at any time
NOTE: All data within the chart note are saved and closed to be
completed at another time
NOTE: An interrupted chart note = an incomplete chart note (i.e.,
no charges billed, no data captured); the chart note must be signed
for the data to become a part of the patient’s record
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Charting
1
A
Interrupt a chart note – 2
 1. Click the INTERRUPT icon within the branching logic
Data Entry screen
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NOTE: All data within the current branching logic sequence (see
the red A for an example) are lost
NOTE: All other data already existing within the chart note is saved
and closed to be completed at another time
NOTE: The interrupted branching logic sequence can be completed
at another time – the opportunity to enter data is not lost
NOTE: An interrupted chart note= an incomplete chart note (e.g.,
no charges billed, no data captured); the chart note must be signed
for the data to become a part of the patient’s record
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Charting
4
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3
Sign & Finish tab (Students must ALWAYS have CI
approval first)
 1. Enter the time you began your appointment with the
patient in the TASK COMPLETED field
 NOTE: You must use military time (24:00)
 2. Enter the total billable AND nonbillable time in
Session duration
 3. Verify the billed items for the chart note
 4. Click the SIGN button to complete the chart note
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Charting
1B
1A
2B
2A
Review charting
There are two ways to review an existing chart note:
1. View Charting – opens a read-only view
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A. Select the desired chart note record
B. Click the VIEW CHARTING icon
NOTE: You can also double-click the desired chart note record
NOTE: This view provides access to the Edit Charting screen
2. Edit Charting – opens an editable view
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A. Select the desired chart note record
B. Click the EDIT CHARTING icon
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Charting
3
4
2
1
View charting
View selected documentation

1. Toggle between the tabs to view the data from the chart note
View other documentation
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2. Cycle through the available chart notes
Edit the chart note
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3. Click the EDIT CHARTING icon
Add an annotation
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4. Click the ANNOTATIONS icon
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Charting
2
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1
3
Edit charting
View selected documentation

1. Toggle between the tabs to view the data from the chart note
View other documentation

2. View previous chart notes through the VIEW PRIOR NOTES
icon
Edit the chart note
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3. Make any free-text edits within the chart template
NOTE: You can add other templates or mini-templates to the note
Add an annotation
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4. Click the ANNOTATIONS icon
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Charting
4
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View prior chart notes
This window is available when you are documenting a new
chart note and allows you to review the patient’s prior
chart notes without having to leave the screen
 1. View charting by Account ID or by Medical Record
Number (MRN) – select in the drop-down menu
 2. Select the desired prior note to view
 3. View the documentation associated with the selected
prior note

NOTE: No charges will display
 4. Click the OK button when done viewing prior notes
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NOTE: This screen ONLY shows signed documents
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Charting
1
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2
3
Locate interrupted charting – 1
Patient Charting tab
 1. Select a patient to display (using Find Patient, etc.)
 2. On the patient’s Charting tab, interrupted chart notes
are bolded and italicized to distinguish them from others
 3. The Charting tab display can be filtered to display
interrupted charting only

NOTE: Select the Interrupted radio button
 4. Click the EDIT CHARTING icon to finish the desired
interrupted chart note
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Charting
A
1
2
Locate interrupted charting – 2
Task List

NOTE: For this Task List Category to display, it must be enabled in
each staff member’s User Configuration settings (see letter A)
 1. Expand the INTERRUPTED CHARTING task list
category (click on the + button)
 2. Select the patient whose interrupted charting you wish
to complete
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NOTE: You can click on the patient in the list or select the patient 22
using the right-click menu
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Charting
1A
1
2
Locate interrupted charting – 2 (continued)
Task List

NOTE: If the Interrupted Charting Task List Category is enabled,
MediLinks will notify you that you have interrupted charting when
you attempt to log out from the main screen
 1. Click the YES button to open the Interrupted Charting
Task List Category and view your interrupted charting

1A. Select the patient whose interrupted charting you wish to
complete
 2. Click the NO button to finish logging out of MediLinks
without completing the interrupted chart note(s)
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Charting
3
1
2
Resolve interrupted charting
Once you are inside of the interrupted chart note, document
as you would in any new chart note:
 1. Check the AUTO-RUN TEMPLATE check box

NOTE: You will start documenting at the first unresolved branching
logic code
OR
 2. Double-click on the desired branching logic code to
continue documenting
 3. Once finished documenting, sign and finish the note
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NOTE: A note can be interrupted as many times as needed
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