Documentation/Clinical Charting
Module guide · Clinical
Clinical Charting
The clinician's working chart: structured notes, vitals, problems, allergies, diagnoses, orders, and every other piece of a patient's clinical record, organized for the bedside.
What this module is for
Where nurses and providers do their actual clinical documentation and ordering, distinct from Patient Records (which handles identity, contact and insurance).
Who uses it
Nurses, physicians, and other clinicians, for charting, ordering, and reviewing a patient's clinical picture during a visit or stay.
Where to find it
Open Clinical Charting from the sidebar. Every screen shares a Patient Search box, so staff always find patients by name or MRN, never by typing an internal ID.
- 1
Home
Find a patient and jump into their chart, or into orders, search, or your dashboard.
- 2
Patient chart
One patient's complete clinical record across 11 tabs.
- 3
CPOE orders
Place, complete, and cancel orders, and co-sign verbal orders.
- 4
Clinical search
Search diagnoses, notes, and allergies across every patient at once.
- 5
My dashboard
Your personal queue of unsigned notes and pending co-signatures.
A few terms used throughout
Clinical Charting Home
The landing page: find a patient, then jump straight into their chart or one of the other tools.
| Field | What it means |
|---|---|
| Patient search | Type a name or MRN to find the patient you want to chart on. |
| Open Chart | Disabled until a patient is selected, opens their full clinical chart. |
Quick-link tiles jump straight to CPOE Orders, Clinical Search, My Dashboard, or the (non-clinical) Patient Records list.
The Patient Clinical Chart
The core screen: everything known about one patient's clinical picture, in 11 tabs. A Print Clinical Summary (PDF) button in the header works from any tab.
Tab 1 · Summary
A read-only, at-a-glance combination of every other tab: latest vitals with NEWS2, active alerts, the problem list, allergies (or "NKDA" if none), active diagnoses, and the 5 most recent notes, each tagged Signed (green) or Unsigned (amber).
Tab 2 · Vitals
Record opens a form: Temp, Systolic/Diastolic BP, Heart Rate, Resp. Rate, SpO2, Pain (0–10), all optional. The table's NEWS2 column shows in bold red once it reaches 5, an early sign the patient needs urgent review.
Tab 3 · Problem List
Ongoing/chronic problems, distinct from time-limited diagnoses. Add needs an ICD-10 code and description, with a "Chronic condition" checkbox. Resolve closes one out.
Tab 4 · Allergies
Allergen, Reaction, Category (Drug/Food/Environmental/Latex/Contrast Dye/Biologic/Other), and Severity. Verify confirms a clinician double-checked it; Deactivate marks it no longer active. Shows "NKDA" if none on file.
Tab 5 · Diagnoses
ICD-10 code, description, and Type (Principal, Secondary, Admitting, Chronic, Comorbidity, Complication, External Cause, or HAC). Resolve closes one out.
Tab 6 · Notes
Structured clinical documentation. New Note asks for a Note Type (SOAP, History & Physical, Progress Note, Discharge Summary, Operative Note, Consult Note, Procedure Note, Nursing Note, Nursing Assessment, Social Work Note, Psychiatry Note, Therapy Note, Patient Education Note, Telephone Encounter Note, or After-Visit Summary) and the note content. Each saved note shows a Signed/Unsigned badge; Sign electronically finalizes an unsigned note under your name, this locks it as authored and attested. Print generates a PDF of that note.
Tab 7 · Goals
Care-plan style goals for this admission/visit (e.g. "ambulate independently by discharge"). Mark Achieved closes one out.
Tab 8 · Alerts
Patient-safety flags any staff member should see, e.g. fall risk. Alert Type, Message, and Severity. Resolve clears one once no longer relevant.
Tab 9 · History
Background history not tied to a specific visit: Medical, Surgical, Family, Social, Obstetric, Psychiatric, Immunization, or Occupational, each with a description. Read-only once added.
Tab 10 · Consent
Signed consent forms: General, Surgical, Anesthesia, HIPAA Authorization, Research, Advance Directive, DNR, Blood Transfusion, Procedure Consent, or Release of Information, with who signed and their role. Revoke cancels an active one.
Tab 11 · Functional
New Assessment records up to four standardized scores, all optional: Morse Fall Score (higher = more fall risk), Braden Score (lower = higher pressure-injury/bedsore risk), MMSE (a cognitive function score), and PHQ-9 (a depression-severity questionnaire). Each saved row also shows a computed fall-risk level next to the Morse score.
Low severity — gray, allergies & alerts
Moderate — amber
High — orange
Critical — red, needs immediate attention
Signed note — green
Unsigned note — amber, still needs the author's signature
CPOE Orders
Where medications, labs, imaging, diet, consults, and procedures get ordered electronically, and where verbal orders taken by phone get their required co-signature.
Verbal orders pending co-signature
Place Order form
| Field | What it means |
|---|---|
| Order Type* | Medication, Lab, Radiology, Diet, Consult, or Procedure. |
| Order Name* | What's being ordered, e.g. a drug or test name. |
| Priority | Routine, Urgent, or STAT (STAT = needs to happen immediately). |
| Clinical Indication | Free text explaining why the order is being placed. |
Each order in the list shows who ordered it and when, its priority, and a status badge. Complete marks it fulfilled; Cancel cancels it with a fixed reason of "Cancelled by provider," both immediate, no confirmation popup.
Draft — not yet finalized
Active — in effect, being carried out
Completed — fulfilled
Cancelled — called off
Clinical Search
One search box across every patient's diagnoses, notes, and allergies at once, useful for audits, outbreak tracking, or finding a specific note fast.
Type a keyword, an ICD-10 code, or note content, then search. Results are grouped into cards by category (Diagnoses, Notes, Allergies). If nothing matches, it says so plainly.
My Clinical Dashboard
A personal work queue, what documentation you still owe, and a history of your own recent work.
Top stat tiles
| Field | What it means |
|---|---|
| Unsigned Notes | Notes you've written but haven't signed yet. |
| Pending Co-Sign | Notes written by someone else that need your co-signature. |
| Recent Notes / Recent Orders | Counts of your recent activity. |
"My To-Do" tab
Unsigned Notes panel, each with a Sign button. Pending Co-Signature panel, each with a Co-Sign button, both immediate, no confirmation.
"My History" tab
Notes I've Authored, Signed/Unsigned badges, with Print per note. Orders I've Placed, a read-only recent list.
Requires your account to be linked to a staff record; otherwise the page explains there's nothing to show.
Good practices
Sign notes promptly
Watch NEWS2 on the Vitals tab
Verbal orders still need a real co-signature