Making Changes to a Chart Entry
There’s a few scenarios that pop up where a chart needs some attention. Jane has a few ways to work with your chart entries, while also remaining compliant with general charting regulations. These regulations typically require original entries to remain legible and all changes to a signed chart to be documented and dated.
The first thing to note is whether the chart entry is in a draft or locked state. Only chart entries still in their draft form can be deleted. If the chart has been locked see the Amend or Change Patient sections below.
If, however, the entry is still in draft form, then it can be removed. The author of the chart needs to be the one to delete the entry.
So for example, you can see below that the entry is in Draft and that it belongs to Susan Lo.
To delete the entry, Susan can open up the chart and then head to the bottom where there will be a “cog” icon. Under the cog drop down is a Delete option.
All done! And when you’re reviewing a chart you can always take a look to see if there are any deleted entries by using the filter at the top of the chart.
Changing the Patient
This is something that can be done whether the chart is locked or still in draft form. We know that things are moving quickly in clinics and that sometimes charts can be created under the wrong patient. We recognize that leaving those entries visible is not an option, so you can move the entry to the correct client.
This can be done in that same menu as the deleting - under the cog at the bottom of the entry.
Jane will leave a record that the entry was moved and where it was moved to.
Changing the Author
From time to time, more than one staff member will need to add information to a chart entry. We see this in cases where, for example, a technician needs to add their findings to the chart before the doctor completes it, or a supervisor needs to sign-off on a completed chart entry of an intern. Jane allows the current author listed on a chart entry to change the author while the chart is still in draft format.
You can learn more about this workflow in our Supervisor Sign Off guide document.
Making an Amendment
If you need to correct or change something that was already signed and locked you can make an amendment.
Again this feature is designed to comply with charting regulations that leaves original entries visible, and dates the amendment.
If you have any questions about this or are running into any trouble please let us know!