Clinical Charting - Consolo Redmine Clinical Charting Entry – Basic Functionality Feb 2014 1 | P a g e Clinical Charting This guide explains basic clinical charting functionality

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Consolo Clinical Charting Entry – Basic Functionality Feb 2014 1 | P a g e

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.

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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:

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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:

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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.

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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.

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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.

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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

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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.

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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

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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”.

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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:

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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:

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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.

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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:

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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.

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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.

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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 email with link to

the specified chart entry

Created by - Name of User who created the entry. Click User name to send an email 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.

Documents

Clinical Charting - Consolo Redmine Clinical Charting Entry – Basic Functionality Feb 2014 1 | P a g e Clinical Charting This guide explains basic clinical charting functionality