Documentation and Charting Overview 

You can view Documentation/Charting from the Case Details tab of the client chart. You can select different types of assessments or visit notes from a library of documents. After you complete the required documentation, the document remains in the client chart. In the charting header, you can view the status of the documentation. For example unsigned, signed or struckout .

When a patient has multiple case records, you can separate charting and the care plan based on the case record selected. For example, the patient has a case record for skilled and private pay services. With each case record, you can view charting and care plan details specific to the services provided.

To add a new document / charting, click Add and a library of different documents appears.

You can complete, view, print, and strike out a document within a patient's chart. To view documents that are signed, unsigned, or struck out, click Audit Trail Report.

  • In security role setup, the following applies:

    • If you have Chart Charting Read/Add/Edit and Assessment Admin marked no, you can edit your own documents but cannot edit any other author's documents.

    • If you have Chart Charting Read/Add/Edit and Assessment Admin marker yes, you can edit your own documents as well as other author's documents.

    • If you have Chart Charting Read/Add/Edit/Delete and Assessment Admin marked no, you can edit or delete your own documents but cannot edit other author's documents.

    • If you have Chart Charting Read/Add/Edit/Delete and Assessment Admin marked yes, you can edit or delete your own documents as well as other author's documents.