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:

Additionally you can now start an assessment/SOAP note from the schedule in Charting+

Assessment

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

• Click Start New Assessment

Complete the patient assessment by filling out the information in each SOAP tab.

• 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

 Objective

Select the tabs to expand these sections in order to input more information

There are two options for the body man - the selection tool (which allows you to select a body part and choose a diagnostic code) and the drawing tool (which lets you circle the areas of the body the patient is seeking treatment for).

This icon when selected will open up the drawing tool. You can then circle the body parts and select save so your drawings will sync into the patient document tab:

The selection tool will always be the default choice and the icon is present when you're in the drawing tool so you can select that to go back to selection mode.

• 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

Analysis

Treatment

• 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 Government Forms and Add another form to view the full list of available forms for all provinces