A Guide to Using the Patient Chart
What is included on the Patient Chart?
From the top down: Client Information, the Communication Log, Patient Documents, and Patient Chart Access.
- The Client information section will auto update as you change each field, and you will see a green check when exiting the box. As this is only the basic information to be edited quickly, further information may be found in the button below: “Edit Client Information”. Included here are also links to the tracking board, the billing sheet, and client info sheet for this patient.
- The Communication log holds all communication between provider and patient. It is a good idea if you log entries about if you speak with the client, call the client, or interact with them. It also is helpful to include other actions taken in regards to client insurance or communication between providers. Therapractic also does automatically generate an entry when the client is assigned to a provider, scheduled, seen, or messaged. If you need to leave a note for yourself, you make uncheck the entry as ‘Shared’.
- The Patient Documents are where all patient documents and assessments are found. The Shared Documents are those that you have uploaded and Shared with other providers. The Private documents are uploaded and are only seen by yourself. Adding a service will create a note below under the blue ‘Medical Health Care Provider’ bar or the green ‘Mental Health Care Provider’ bar. An external service is one that you may have completed on paper, but wish to upload and track in Therapractic. You may attach a visit time and billing code to an uploaded external service. Download notes will create a .zip file on your computer, containing all notes associated with the client. Remove blank notes will delete all notes that have not had anything added to them. This, however, does not include progress notes that have had information transferred to them by an inital assessment.
- At the bottom of the Patient Documents section, you’ll find the list of assessments or visits that have been performed. Keep in mind that the ‘Begin as client’ button will log you out, as it allows you to give a device to the client to fill out without having access to ePHI (electronic protected health information. You will click on ‘Begin’ to fill out the note as the provider. You may also click on ‘Email to Client’ to send them a link to fill out the questions that apply to them in an intake format.
Note: The time displayed on the visit is what you have marked under the first visit code in the note page after clicking on ‘Begin’.
- The Patient Chart Access section is only visible to certain providers on the chart, including the originating entity who created the client, and the currently assigned provider. These providers may grant or remove access to others who hold accounts in Therapractic, though, we stress that they MUST assure that this person is authorized to review the patient’s ePHI. This also applies to the buttons at the top of the Chart Access area: the ‘Send Update to Provider’ button, which will notify those who have been granted access to the chart via email; as well as the ‘Email Client Information’ button, which will allow you to send a link via email containing a token that will allow that address to review the Patient chart as is (excluding any events that occur after the email is sent).
Who will see the information that is on the Patient Chart?
The Patient Chart was designed for a multidisciplinary practice. This is so that multiple types and professions of healthcare providers to track a singular patient’s progress. Just like in a physical clinic, if a file was kept in the records room, certain individuals would be able to have access to that file. The patient’s medical provider and mental health provider will be the primary users of the Patient Chart. As such, they may designate other providers to have access to the chart as appropriate at their disgression. It is crucial that the patient sign the provided documents, including consent to treat forms, authorizations for release of information, and notices of privacy.
Does the Patient Chart comply to HIPAA regulations?
First of all, Therapractic uses 256-bit SSL encryption on all pages, meaning data transmitted over Therapractic is always encrypted.
As far as the practices on the Patient Chart, the system will not allow access to any provider unless a knowing provider gives them said access. It will be important for you to make sure, anytime you refer the patient or sent patient information, that the person to whom you referred the patient is authorized to do so.
Best practices in using the Patient Chart
In the use of the Patient Chart, there are a few things we would recommend for you to use it in the simplest and safest ways:
- Make sure to include any and all communication with the client in the communication log. This does not include private information about the patient’s health, only your responsibility in providing care to them.
- In the Patient Documents section, check to see that no private documents such as raw psychological testing or notes are in the Shared section.
- Upon completion of a note/visit, review the information included in the assessment and make sure it can be shared with their doctor or future therapists before you complete the note mark it as “visible to doctor”. Otherwise, you may complete the note and make sure it is not marked as visible.