NS - Knowledgebase

A treatment plan is the document the patient takes away - what to do, what to take, and how. It is built from the encounter, and it prints as a clean patient-facing page rather than as a copy of your clinical note.

Open the plan

Open the plan from the encounter you are working in. It opens showing the document as the patient will receive it, with the patient's name, the date, you as provider, and a DRAFT watermark across it until it is finished.

The list on the left, headed T:// TXPLAN, shows the sections the plan is made of. Which sections exist is set up once for the practice - see Configuring your ChartPro Service.

Fill it in

Each section has an Edit pencil beside it. Click it, write the content, and it appears in the document straight away, so you are always looking at what the patient will see.

Two kinds of section behave differently:

• Free-text sections such as Diet Therapy hold advice in your own words. Practices usually keep standard wording for these so the same advice does not get retyped, with the specifics filled in per patient.
• Dispensary Items lists what you are dispensing or recommending, each with its own Instructions: line - "Take two capsules three times a day, between meals" and so on. This is the part patients actually follow, so it is worth being specific: with food, at night, away from other supplements.

Finish it

Save & Document finalises the plan and produces the patient copy. Close leaves it as a draft to come back to.

A plan left in draft is not lost, but the patient has nothing - so finish it before the patient leaves rather than intending to come back to it.

Making it useful

• Write for the patient, not the chart. The plan is read at home, days later, by someone who was taking in a lot at the time. Plain instructions beat clinical shorthand.
• Say how, not just what. A supplement with no timing or food instruction gets taken wrongly or not at all.
• Keep it short enough to follow. A plan with four things a patient will do beats one with twelve they will not.
• Standard wording saves real time - the advice that does not change between patients only needs writing once.

Dispensary items on the plan are the same products as in your catalogue, so the instructions can come from the product record rather than being typed each time. See Adding and Editing Products.

Auto Chart records a consultation, transcribes it and drafts the chart note. You read the draft and decide whether it goes in.

Before you start

Open the note on the right visit - the AI is given that visit's Patient, Provider, Visit Type and Date of Service, and it uses them. Starting from the wrong visit produces a plausible note about the wrong context.

Tell the patient what you are doing, in whatever words your practice has agreed.

Recording

Auto Chart opens the listener and starts recording; you will hear a tone. The panel shows your use for the month against 40.

Things that make the difference between a good draft and a poor one:

• Put the microphone nearer the patient than to you. Your own voice is never the problem.
• Say numbers, doses and units out loud and clearly - they are what transcription gets wrong, and they are what matters most.
• Say names of medicines in full rather than abbreviating.
• Summarise your plan aloud at the end. It gives the draft a plan to write, and it is good practice with the patient anyway.
• Close the door. Background conversation ends up in the transcript.

Reading the draft

When it finishes you get AI Note Preview - Review the AI-generated chart note below.

Read it properly. Check the numbers against what you remember, check nothing has been attributed to the patient that they did not say, and check nothing has been invented that sounds reasonable. A draft that reads well is not the same as a draft that is right, and once you accept it, it is your note.

• Accept it and it is written to the chart - you will see Chart Updated and Your AI note was saved.
• Go back and re-record if the recording went wrong and you would rather start again.
• Cancel discards the draft. Nothing is written.

Edit the note afterwards exactly as you would any other. The draft is a starting point, not a finished document.

Rating a note

Rate This Note asks about Transcription Accuracy, AI Note Quality and an Overall score from Poor to Excellent, with Comments, then Submit Rating.

It genuinely is read - Your rating helps us improve ChartPro AI. Rate the ones that came out badly and say what was wrong in the comments. Almost nobody rates anything, so a specific complaint carries real weight.

Looking back at what it wrote

The review link beside the button opens ChartPro AI - Encounter Review, listing your encounters by Date and Encounter # with their Note Quality, or Not rated.

Opening one shows the Transcript next to the ChartPro AI Note. If you ever want to know whether it misheard something or invented it, this is where you find out.

The IV builder records what actually went into the bag: the diluent, every component with its dose and lot, the calculated osmolarity, and the administration details. When the treatment is administered it posts the charges, moves the stock and writes the record into the chart note.

Open the panel:

• Open the encounter and start or edit a chart note.
• Find IV Therapy in the sidebar. If it is not there, the segment has not been attached to this note's section yet.
• Click + New IV, or pick a protocol from the list to start from a formulation.

Build the bag:

1. Choose the diluent and its volume - the carrier the additives go into.
2. Add each component by searching for it. Type a dose and the volume is worked out for you; type a volume and the dose is worked out instead. Whichever you typed last is the one kept, and the derived figure is shown in a lighter weight so it is clear which is which.
3. Record the lot number and expiration date for each component. A lot past its expiration date is flagged immediately.
4. Set the route (infusion or IV push), access (peripheral, central or port), site, rate and duration.

Read the osmolarity: the summary updates as you type and bands the result - under 500 mOsm/L is within the range routinely given peripherally, 500 to 900 is peripheral with caution, and above 900 indicates central access. If any component has no osmolarity on file the figure is marked as a lower bound rather than a final number.

These are osmolarity bands, not tonicity. A bag at 280 mOsm/L is not therefore "isotonic": dextrose counts fully toward osmolarity and is then metabolised, so D5W is iso-osmolar and hypotonic. The module reports the number it can calculate and does not infer tonicity from it.

Administer: this is the only step that cannot simply be undone, and it confirms first. It stamps the start time, marks the treatment administered, posts the charges, decrements stock and inserts the record into the note. If the calculated osmolarity indicates central access but peripheral access is selected, you are asked to acknowledge that explicitly and the reason is recorded.

What reaches the encounter: each billable component becomes its own service line carrying its billing code and the correct number of units, alongside any administration lines the protocol defines. Stock is decremented for every mapped component. Clicking Administer twice does not double-post - the second click does nothing.

The note: the inserted block is the full compounding and administration record - components with doses, lots and expirations, total volume, osmolarity with its band, beyond-use date, route, access, site, rate, start and stop times, and who administered it.

A compounded bag has a beyond-use date, which is how long the mixture stays usable after it was prepared. That is a different thing from the expiration date printed on a vial as supplied, and both are recorded.

The acupuncture panel sits in the encounter sidebar. It is a launcher and a summary; the charting happens in the window it opens.

Start a treatment

• Click + New treatment to start from nothing.
• Choose from Apply a protocol… to start from a saved prescription.
• Under Previously, click a past treatment to copy its points onto today’s encounter.

Cloning copies the prescription — the points, sides, depths and techniques. It deliberately does not copy what happened: times, needle counts, de qi, pain scores and contact time all start clean, because they are a record of a different session.

Add points

• Type in Find a point to search by code, pinyin, English name or Chinese characters. LI4, LI-4, Hegu and 合谷 all find the same point.
• Narrow the list with Channel.
• Click Add an ashi point for a tender point with no code, and name the muscle.

A point carrying a caution shows a marker in the search results. Hover it to read the caution. Nothing is ever blocked — the cautions are there to inform your judgement, not to overrule it.

Tick show every field for direction, gauge, length, e-stim pairing and the rest.

Record the time — the part that matters for billing

There are two different durations and they are not interchangeable.

Use Start timer when you are with the patient and Stop timer when you leave them, or type minutes into Or add and choose what you were doing. The timer uses the server clock, not the clock on the computer you are working at.

Time the patient rests alone with needles in is documented care, but it is not personal one-on-one contact and it is not billable as such. Billing retention time as contact time is the single most common finding in an acupuncture audit, which is why this software keeps the two figures apart and offers no way to copy one into the other.

Count the needles out

The Needle count chip at the top of the window tracks whether everything that went in has come out.

• In the Removed column, blank and 0 mean different things. Blank means nobody has counted yet; 0 means you counted and none came out.
• Tick Retained for a press tack or intradermal needle left in on purpose. Those are subtracted from what has to come out, so deliberate retention never makes a correctly finished session look unreconciled.

Post the charges and write the note

Nothing you do in the charting window reaches the patient’s ledger. Saving is safe and automatic. When the session is finished, post the treatment to put the charges on the encounter, and click to note in the sidebar to add the write-up to the chart.

A treatment can only be added to the note once. If you genuinely want it twice, the software asks first.

Welcome to ChartPro where you can easily and competently document your encounters with patients with ease. To get started, click on the [C] button in the visit icons area on any visit. The [C] button allows you to access the chart note for a particular visit. To learn more about visit icons and visit workflow click here.  

Establish a Patient Visit:

• Before you can create a chart note, ensure that you have established a visit for the patient you want to document.

Access the Chart Note:

• From the visit details, locate the visit icons list and click on the ChartPro note icon (represented by the [C] icon).

Navigate to the ChartPro EMR Interface:

• Once you click the icon, the chart note interface will open, starting with the Subjective section of the note.

The ChartPro interface will load for this visit in a popup window and will put you right into the primary segment of the chart (usually, Subjective > HPI). The charting interface is organized in a compact but robust way to help you document your visits easily, accurately, rapidly, and effectively. To make the most of your charting experience familiarize yourself with the charting environment. Let's start with a description of the interface: 

Adding Content:

• Under the Subjective section, use the WYSIWYG (What You See Is What You Get) editor to add any content you wish to document. You can format the text using the available editing tools.

Incorporate Preformatted Content:

• On the left side of the note editor, you'll find a menu with preformatted content specific to the segment you're in. This includes:
  • Paragraphs
  • Statements
  • Forms
• Select any preformatted content you wish to include in your note.

Complete Other Segments:

• After finishing the Subjective section, you can navigate to other segments using the Section Browser located at the top of the editor. Each segment will have its own set of helpful statements, links, contents, and forms.

Save Your Note:

• Once you've completed the chart note across all necessary sections, make sure to save your work to keep the information recorded.

Additional Tips:

• Explore all segments to utilize the full range of tools and content available in the ChartPro interface.
• Familiarize yourself with the WYSIWYG editor to enhance your documentation process.

This guide should help you get started with creating chart notes effectively in OfficePro.