Lock & Timestamp Chart Notes or Add an Addendum

Healthie's Charting Feature enables you to save, sign, and lock your charting notes. After a chart note has been locked, they can be edited solely through a Chart Note Addendum. Additionally, locked charting notes receive a timestamp.

In order for a provider to Sign/Lock their own Charting Note, they need to have the correlating Permission for Charting enabled.

Charting Note Options

When editing a charting note, you'll notice a Save button on the top-right. While Healthie automatically saves your charting note, you can manually push the button to ensure your progress is saved. 

Within the Save button, there is a drop-down selection with more Saving options: 

• Save and Close: provider can save note only, returning to edit, sign, or lock at any time.  
• Sign Note: provider can add a digital signature to the note.
• Lock Note: provider can lock note and prevent further edits, apart from addendums
• Unlock Note: providers who have the unlock chart note permission enabled can unlock notes
• Sign & Lock: provider can add a digital signature and lock the note, preventing further edits apart from addendums.

Benefits of Locking Chart Notes 

As an industry best-practice, providers can lock their chart notes after finalizing them, as a permanent record following a client session. The advantages of doing so, are to ensure that:

• Once a chart note is considered final by the provider, it is not subsequently modified 
• Other providers & administrators in the organization cannot write-over or retroactively make edits to a charting session 
• Any updates needed to a Chart Note are logged separately as an addendum, and/or in some cases, as a New Updated Chart Note

Lock & Timestamp a Chart Note

To lock a chart note, navigate to the client's profile and either start a new charting note, or edit an existing note. 

• Open/Edit a charting note 
• Select the drop-down option next to Save 
• Select Lock Note

Note: If there are required fields in a Charting Template, then the provider will be prompted to complete any missing required fields before the note can be locked. 

Once locked, an indicator will appear, showing that the chart note is locked. A note cannot be edited further by any team member. 

When other care team members view the charting note, they will see the indication that the charting note has been locked in the Chart Note History. 

Add an Addendum to a Locked Chart Note

Once you've locked a chart note, you may not make any edits to the content of the note. However, you can add an addendum if there is additional information that needs to be added post-signing. 

To add the addendum, navigate to the charting area of the client's profile and select the desired chart note. Click on the blue "View Note" button, and scroll to the bottom of the note. From there, you can type and save the addendum so that it is attached to the previous content of the chart note. You will be able to see the date and time the original note was locked, as well as which provider it was locked by (if you work in a multi-provider practice). 

Unlock a Chart Note

Team members are able to unlock chart notes if they have the "Can Unlock Chart Notes" permission enabled (Organization>Members>Permission Settings>Charting). By default, this permission is ON for Organization Owners and OFF for non-Org Owners and can only be enabled by an organization owner.

If enabled for a user, they will see the option to "Unlock Note" when viewing a specific chart note in the top right corner.

Once a user tries to Unlock a Note, they will be view a Notice of Data Integrity and be prompted to add a Reason for Unlocking. Once the update is made, users can re-lock the chart note. Any edits made will be recorded in the chart history.

Other Providers Adding an Addendum

Multiple team members are able add an addendum to a charting note. 

In order for to add an addendum to another provider's note, an account admin will need to enable the following setting: 

• "Can write addendums to charting notes of other providers."
• Provider must either be a Care Team member for the client, or have permissions to "View All Clients" across the organization in order to access charting for the client.
• The provider will see the Chart History section for the client, and will be able to add an addendum accordingly. 

Have a Team Member Review a Chart Note

One common utilization of charting addendums is to have a Supervisory provider review a locked note, and add an addendum that they have reviewed the note (with any comments they would like to add). 

If you would like a specific provider to be alerted to review a charting note, we recommend using Healthie's Task feature. 

• Create a task and assign it to the provider. 
• Tag the client in the task, so the provider knows which client the chart note refers to (clients are not notified, and do not see tasks). 
• Optionally, add a due date for the task and set a reminder for the task. 
• Optionally, set the task as high priority, 

The provider will be notified of the task, and see it in their pending tasks. They can check off to mark the task as complete. 

Learn more about how to use Tasks for Organizations.