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 THIS ARTICLE:
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.
Click on the Charting tab. From here, you have two options:
- Lock a previously written chart note
- Write a new chart note start to finish and lock it at the end of the session.
1. Lock a previously written chart note
To lock a previously written chart note, click on "View Chart Notes" within the charting area of the client's profile. Click on the blue "Edit" button. From there, you can make any last changes to the chart note before locking it. Once you are ready to lock, click on the drop down button next to the blue "Save" button, and select "Sign and Lock." Healthie will prompt you to confirm that you would like to lock this chart note; once it's locked, no changes may be made - although addendums can be made by the chart creator.
2. Write a new chart note start to finish and lock it at the end of the session
To lock a chart note that you have just completed, the steps are essentially the same. Once you are ready to lock, scroll to the top of the note and select the drop down next to the blue "Save" button and click "Sign and Lock."
Save and Close vs Lock and Close
Note: If you have required fields in your Charting Template, you, or providers on your team, are able to "Save & Close" the note, but are not able to "Sign and Lock" the note. If a provider tries to "Sign and Lock" the note, then they will be prompted to complete any missing required fields.
Add an Addendum to a Locked 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. Note: Only the provider who wrote the note can add the addendum.
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).
Planned updates will allow multiple care team members to add an addendum to a charting note. We'll update this article when the release goes live.