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Charting the Initial Assessment

Note: Be sure to check out the Scheduling Notes before beginning in case there is anything you need to know!

Search and Open Patient

Find your patient and choose “Open Patient” or click on the patient’s name:

Assessment

For new conditions, begin the session with a new assessment.

  • Click “Start New Assessment”

  • Create the appointment, then “Continue to Note”

  • Enter all applicable charting information on the Subjective, Objective, Analysis and Treatment tabs

  • The mail icon indicates that the associated field is mandatory for Engage Email Communications
  • The information icon indicates that the associated field is used to populate forms

  • Use the body man on the Objective tab to select the body area of injury, and you will then be prompted to select an appropriate diagnostic code related to that area of injury. Diagnostic Codes are available but are only required for OHIP and MVA/MVC patients.

FEATURE: The diagnostic codes that are available to you are dynamically populated based on the province of the patient and the funding stream selected on their appointment

  • “Discard” if you would like to delete the note and the information you entered
  • “Save for Later” at any time throughout Charting+ if you are not ready to complete the note

  • “Complete Note” when you are finished the chart. You cannot go back to edit this note once completed
  • When the chart is completed, you can review and print if necessary

Producing Forms 

After you complete an assessment, a pop-up window will appear with form recommendations to be produced. Form recommendations are based on the province of the patient and the funding stream selected for their appointment.

  • Click Download PDF next to the form you would like to produce
  • A new window will open with corresponding form populated with the data from the patient’s profile and your complete assessment data.
  • Review this form to ensure the information is correct and continue to complete the missing information prior to saving or printing
  • NOTE: You will need a PDF reader program to view and complete forms
  • Click “Add another form” to view the full list of available forms for all provinces

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