Document care plan progress for a patient

Path: Patient>Clinical>Care Plan Charting

Prerequisite: To document care plan charting, you must have a time log active for the patient visit in Transactions>General>TimeLog.

1. In the Patient component, select a patient.
2. Go to Clinical>Care Plan Charting.
3. Select a service in the upper panel of the Patient component.
4. Verify the correct discipline is selected. 
   By default, this discipline is the discipline of the user who initiated this visit in the TimeLog window. If needed, you can view or document the goals and interventions of other disciplines.
5.  Select the care plan you want to document in the left section of the window.
6. If you want to select NA (Not addressed) and NR (Not reviewed) for all goals and interventions and complete the care plan charting, click Finish.
7. For each goal associated with the care plan, select one of the following:
   1. Y – If the patient is meeting expected progress. Select an appropriate milestone.
   2. N – If the patient is not meeting expected progress. Select an appropriate milestone.
   3. NR – If you did not review this goal during this visit.
8. For each intervention associated with the care plan, select one of the following:
   1. Y – If the intervention has been done during this visit. Select an appropriate milestone.
   2. N – If the intervention has not been done. Select an appropriate milestone.
   3. NA – If this intervention has not been addressed during this visit.
9. To enter the care plan charting notes, click the Notes tab.
10. After all Goals and Interventions are 100% Complete, click the padlock icon to apply your electronic signature and lock the Care Plan Charting for this visit. 
11. In the Confirmation window, click Apply Signature.
12. Save your changes.