Patient's Chart Navigation

This page will walk the user through the patient's electronic record, detailing each tab, icon, and screen.

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Navigating the Patient’s Chart

After selecting a patient you would like to view, the Patient’s Chart window will open. This guide will walk through the patient’s chart in greater depth.

The top row of the patient’s chart features the following information:

  • Patient’s Photo – To take a picture of the patient using your attached webcam, double-click on the No Photo Available icon. This will open the Webcam window. Select the device from the devices drop-down menu, as well as the resolution, and click “start” to start the webcam. Click Capture to take the picture.
  • Patient’s Name – The patient’s name will be listed at the top of the screen beside the patient’s image.
  • Demographics – This button will allow you to open the patient’s demographics to modify any demographic information for that patient, such as name, age, gender, etc.
  • Quick Scan — This button will instantly scan to the patient's multimedia, using the scan settings located under Options.
  • Statement — This button will instantly allow you to print a patient statement.
  • CCDA — This button will instantly allow you to send a patient CCDA to their direct email.
  • Clear Patient – This button will allow you to clear the current patient from the screen and open a blank screen in its place.

The second row of the patient’s chart, immediately under the patient’s name, provides at a glance the patient’s Account Number, Date of Birth, Age and Gender.

The third row of the patient’s chart features several patient specific actions that can be utilized to place orders or enter patient specific information.

  • Medications/Allergies – This button will open the Medications and Allergies screen in the patient’s chart, allowing you to record and print all current medications and allergies for this patient.
  • Problems/Diagnoses – This button will open the Problems screen where All Active Problems and all Inactive/Resolved Problems can be reviewed. New Problems can be added from this screen as well. To close this screen, click Cancel. To save any changes made, click Save.
  • Rx – This button will open the prescription wizard, which will allow you to write a prescription for this patient from their chart.
  • Alerts – This button will open the Patient Information screen, allowing you to add pop-up alerts to the patient’s chart. These alerts can be utilized to notate important information for your patient and will appear whenever action is taken on this patient’s chart. Whenever a patient has an alert, this box will be orange.
  • Hemoglobin A1c (HbA1c) — This button will open a screen to add an A1c level record. Click Add to add a new, modify to modify, and delete to delete.
  • Summary — This action will generate a patient’s summary of basic patient information. You may customize what information is generated with the check-boxes on the left-hand side of this window. You may also update the defaults for your patient summaries under options.
  • Orders – The Orders drop-down menu will allow you to place Radiology, Pathology, or Laboratory orders from inside the patient’s chart. Under orders you will also find a link for TigerView. If the office uses TigerView integration, clicking this link will open the patient's chart in TigerView.

Actions

This drop down menu will provide additional options for information to be entered and recorded in the patient’s chart.

  • Groups — This action will add the patient to a patient group. To add a patient to a group, click the green Add button, then search for the desired group. Click OK to finalize. Groups are covered more on the Advanced Patient Search portion of the wiki.
  • Amendments – This action will allow you to document any changes made to the patient’s demographic information for auditing purposes.
  • Immunizations – This action will open the Export to Immunization Registry window which will be used to export immunization information to a local immunization registry.
  • Import Lab Results – This action will allow you to import HL7 lab files into the patient’s chart for documentation.
  • Pharmacies – This option will allow you to set a default or preferred pharmacy for this particular patient.
  • Quality Measures – This action will open the Clinical Quality Measures window where all quality measures pertaining to this patient may be answered.
  • Referrals – This action will serve as a location to document all incoming and outgoing referrals for this patient.
  • Summary – This action serves the same purpose as the Summary button.

Tabs Overview

There are several tabs that break down the workflow and navigation of the patient’s chart. These are as follows:

  • Workspace – The Workspace tab of the patient’s chart will be the focal point of the practice’s workflow in TRAKnet. This tab contains many individual parts of its own as well as the highly customizable dashboard.
  • All Documents - The All Documents tab of the patient's chart will allow you to view a patient's previous notes, referral letters, CCDA's, secure messages and phone messages.
  • Multimedia – The Multimedia tab of the patient’s chart will allow you to add any images or electronic files to the patient’s chart. You can then view all images and files in this tab in a Windows Explorer view.
  • Billing – The Billing tab of the patient’s chart will allow you to view and enter the patient’s insurance, review the patient’s Ledger, and create and view all Patient Statements for this patient.
  • 20/20 Imaging - If the practice uses Opal-RAD by 20/20 Imaging, the 20/20 Imaging tab of the patient's chart will allow you to see the patient's x-rays taken in the office.
  • Appointments - The Appointments tab of the patient's chart will allow you to view all of the patient's appointments, with filters to see certain date ranges and to see deleted and cancelled appointments.
  • Progress Notes – The Progress Notes tab of the patient's chart will allow you to add, modify, remove, restore, delete or rename a patient's encounters.
  • Phone Messages – This tab will show all phone messages that have been generated for that patient. Phone messages can be added by clicking the Phone Call/Message button on the right-hand side of the patient’s chart and filling in all desired information.
  • Secure Messages — Secure messages that have been imported into the patient's chart.
  • Encounters (2.0) – The Encounters (2.0) tab will show all encounters which were created in TRAKnet 2.0. These encounters will be in Read Only mode and cannot be modified, but they can be printed or deleted.

Workspace Tab

The workspace tab is the primary tab on the patient’s chart and will automatically open upon opening an individual patient. This tab is in itself broken down into several other categories:

  • Dashboard – The Dashboard tab will open the Dashboard where all patient information can be viewed and collected. For more information on using and modifying Dashboards please refer to our Dashboards portion of this guide.
  • Audit Log – This tab will show an Audit Log of only this patient to document all changes and modifications made to the patient’s chart, when they were made, and by who.

On the Dashboard tab, there are a variety of additional navigational options on the right-hand portion of the screen.

  • Open – This button will open the most recent visit for this patient.
  • No Tasks – This button will be grayed out if there are no tasks to perform for the patient’s current visit. If tasks exist for the current visit, this button will become active to view the list of visit-specific tasks.
  • Superbill – This button will open a printable superbill tailored to this patient.
  • Checkout – This button will checkout this patient from his or her current visit.
  • Phone Call/Message — This option will allow you to send internal messages among your practice staff and document all phone calls and notes shared with this patient.
  • No Pending Tasks/X Task(s) – This button will show all pending tasks still to be completed for this patient.
  • Vitals – This button will allow you to add vital signs to the patient’s chart.
  • All Encounters – This button will open the list of all encounters for this patient. Encounters can then be opened from this screen for review.
  • New Encounter – This button will create a new encounter for this patient.
  • Labs – This will show all labs, lab results, and lab orders for this patient.
  • Print Forms – This button will allow you to print patient specific forms for this patient.
  • Patient Forms – This button will allow you to generate patient forms such as consent forms, imaging results, etc.
  • Patient Notes – This box will allow you to free type any patient specific notes or comments regarding this patient. Once text has been entered, the “Update Patient Note” button must be selected to save the patient’s note.

Along the bottom of the screen:

  • HPI – This button will open the history of present illness screen, where HPI information for this patient’s most recent visit can be entered and subsequently inserted into the encounter for this date of service.
  • ROS – This button will open the Review of Systems screen, where ROS information for this patient’s most recent visit can be entered and subsequently inserted into the encounter for this date of service.
  • Medical Hx – This button will open the Medical History screen where all Medical History for this patient can be recorded. Once this screen has opened, click the desired history items from the right-hand portion of the screen to make these selections, then click “Save.”
  • Surgical Hx – This button will open the Surgical History screen where all Surgical History for this patient can be recorded. Once this screen has opened, click the desired history items from the right-hand portion of the screen to make these selections, then click “Save.”
  • Referrals – This button will allow you to generate a referral letter for this patient. Referral letters can be created under Manage Templates.
  • Meaningful Use – Another option for accessing meaningful use relevant material such as referrals.
  • Social Hx – Social history will be documented here.
  • Family Hx – Family history will be documented here.
  • Past Hx
  • Visit Data
  • Patient Engagement – This button will be where patient education documentation as well as patient care documents can be printed for this particular patient.

All Documents

The patient's documents are located here, including their encounter notes, referral letters, CCDA's and messages. Documents can also be printed by clicking the Print button.

Multimedia

The patient's Multimedia files are located here. You can either add by scanning an image, uploading an image, or by taking a new image with an attached webcam. The multimedia filepath is set under options. Multimedia is a common point of failure for many offices. For general multimedia assistance, check the troubleshooting multimedia page.

Billing Tab

The billing tab contains several subcategories where billing related patient information can be entered, viewed, and generated.

Insurance

Patient's insurance will be documented here. To add a new insurance record, click Add when under the Insurance category. You must fill in: Insurance Name and Subscriber No.

Ledger

The ledger serves as an overview of the patient's previous balances, encounters, payments, and other such information. The ledger has four views:

  • Simple — An overview of all dates of service with a breakdown of treatments, payments, comments, and remaining balances. Unapplied payments for this patient also appear at the bottom of this view in red text.
  • Encounters — An overview of only dates of services and balances.
  • Charges — A breakdown of each charge given to this patient regardless of responsibility or balance.
  • Insurance Pending — A breakdown of each insurance responsible charge given to this patient.
  • Patient Responsibility — A breakdown of each patient responsible charge given to this patient.
  • Payments — A breakdown of all payments, both patient, provider, and insurance, posted to this patient.

The ledger also has several filters available to control the information present. These include: date range, type of payment, type of charge, location, provider, and status.

At the bottom of the ledger is an aging report showing the balance broken down by 0-29, 30-59, 90-119, 120+ days for both the patient responsible and insurance responsible balances.

Statements

All past statements created for this patient are visible here. They will be listed with the following information:

  • Date Generated
  • Date Due
  • 0-29, 30-59, 60-89, 90+ — Aging reports for the given date ranges. How much of the balance falls under each.
  • Total Charges
  • Total Credits
  • Balance
  • Remit To

If the setting under options was appropriately set, statements will save under the patient's Multimedia file when generated. To generate a new statement, click Add.

Authorizations

Referral Authorizations for this patient will be documented here. To add a new referral authorization number, click on the Authorizations category, then click Add. Enter the following information in the editor window:

  • Insurance — The patient's insurance (required).
  • Referral Authorization Number — The referral authorization number (required).
  • Referral State Date — Start date for the referral period (required).
  • Referral End Date — End date for the referral period (required).
  • Referral Visits — Number of visits allowed.

Visits will automatically deduct each time a claim is sent for this patient and a referral authorization number is present.

Remarks

Remarks are billing specific patient notes and comments. To add a new remark, click on the Remarks category, then click Add. A pop up window will load where all information, including a title, will be entered. Remarks are recommended for billing notes only, e.g. calls to the patient's insurance company, remarks about the patient's balance, etc. Remarks are then visible on the invoice of any claim for this patient.

Appointments Tab

The appointments tab contains a list of all scheduled appointments for this patient. There are several filters on this screen to show all appointments, appointments in a date range, and whether or not Cancelled and Deleted appointments should be included. To refresh the appointments tab, click the Search button in the upper right-hand corner.

Progress Notes

Progress notes are all previous encounters created in TRAKnet 3.0 for this patient. Encounters can be created, opened or deleted, and deleted encounters can be shown by checking the Show Deleted checkbox, and subsequently restored with the Restore button. The title of an encounter can also be changed with the Edit Properties button. Please note that the date of the encounter will always prepend to the title of the encounter if it is not already there, so do not change the date on the title; If you need to change the date, instead change the date in the encounter. You can also print encounters from this tab with the Print button.

Phone Messages

Phone messages with this patient will be recorded here. Phone messages are entered from the Phone Call/Message button on the Workspace tab of the patient's chart. They are free text documents that can be assigned to another user in the office as a reminder. From the Phone Messages tab they can be printed, viewed, or faxed.

Secure Messages

Secure messages which have been imported into the patient's chart will be available here. They will be listed by date and will appear in a print preview format. They can then be printed, deleted, or faxed. Secure messaging is a portion of meaningful use.

2.0 Encounters

Encounters from TRAKnet 2.0 will be visible here. They will be in read only mode: they cannot be opened or edited, but they can be deleted. However, you may print them, fax them, or copy and paste their content from the 2.0 Encounters tab. They will be ordered by date and show all basic information.

Multiple Patient Chart Tabs

Multiple patient charts can be opened simultaneously, separated by tabs. To close a tab, select that patient's tab and click the Close Patient button. To close every patient chart tab, right click on any of the tabs and click Close All.

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Additional Materials

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