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 / 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
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.
IN THIS ARTICLE:
Locking 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 "Save and Sign." Healthie will prompt you to confirm that you would like to lock this chart note; once it's locked, no changes may be made.
If you select the "Don't show this notice again" checkbox, you will no longer receive a prompt to confirm that you would like to lock the note; instead, once you've hit "Save and Sign" from the drop down, the chart note will lock automatically.
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 "Save and Sign." This will again prompt you to confirm you would like to lock the note, and prevent any further changes from being made.
Save and Sign vs Save and Close
Note: If you have required fields in your Charting Template, you, or providers on your team, are able to "Save and Sign" aka Lock the note, but are not able to "Save and Close" the note. If a provider tries to "Save and Close" the note, then they will be prompted to complete any missing required fields.
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. 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).