In Chart, you can chart completed treatment.
Note: Charting completed treatment requires the "Completed Procedure, Enter" security right.
To chart completed treatment
With a patient selected in Chart, if applicable, select a provider other than the default chart provider for the patient's charting session.
Note: The selected provider will be assigned to all procedures, conditions, and diagnoses that you chart during the current charting session.
If the completed treatment that you are charting requires a tooth number, select the applicable teeth in the graphical chart.
Do one of the following:
Click a procedure button.
Click a procedure code category button. The Select Procedure Code dialog box appears. Select a procedure code, and then click OK.
On the menu bar, click Procedures. The Procedure Codes dialog box appears. In the Category list, select a category to view the corresponding procedure codes. In the Procedure Code List, select a procedure code, and then click OK.
On the menu bar, click Multi-Codes. The Select Multi-Code dialog box appears. Select a multi-code (a set of related procedure codes that are typically done at the same time), and then click OK.
Enter a procedure code in the Procedure box (the right box below the status buttons). If applicable, enter the first letter of each surface, separated by commas, in the Surfaces box (the left box below the status buttons); or you can select them later. Skip steps 4-5.
Do one of the following:
If the selected procedure requires the selection of quadrants, sextants, or arches, the Quadrant Selection, Sextant Selection, or Arch Selection dialog box appears. Select the applicable treatment areas, and then click OK.
If the selected procedure requires the selection of surfaces, the Surface Selection dialog box appears. Do one of the following:
To select surfaces later, click Cancel.
To select surfaces if one tooth is selected:
Select the checkboxes that correspond to the correct treatment areas.
Click OK.
To select surfaces if multiple teeth are selected:
With the first tooth selected in the list on the left, select the checkboxes that correspond to the correct treatment areas, and then click Add.
Do one of the following for the other teeth listed:
To apply the specified surfaces to all the other teeth listed, click Apply to all teeth. On the confirmation message that appears, click either Yes to apply the surfaces to all the teeth listed (you can change the surfaces of any tooth as needed before you click OK) or No to apply the surfaces to only the selected tooth (you must then add surfaces to each tooth separately before you click OK).
To add surfaces to each tooth separately, select a different tooth in the list on the left, select the checkboxes that correspond to the correct treatment areas, and then click Add. Repeat this process as needed for the other teeth listed.
Notes:
You can also change the surfaces for any tooth in the list by selecting that tooth.
To continue, every tooth in the list must have at least one surface applied to it.
Click OK.
If the procedure requires the selection of surfaces, and if you skipped the selection of surfaces in step 4, enter the first letter of each surface, separated by commas, in the Surfaces box (the left box below the status buttons); or you can select the surfaces later.
Click the Complete status button.
If applicable, do one of the following:
If the Password - Completed Procedure, Enter dialog box appears, user verification has been assigned to the "Completed Procedure, Enter" task. Do one of the following:
If your user account has been granted the "Completed Procedure, Enter" security right, enter your credentials in the User ID and Password boxes, and then click OK.
If your user account has not been granted the "Completed Procedure, Enter" security right, have a user with permission temporarily override this restriction so you can chart a completed procedure this one time. The overriding user enters his or her credentials in the User ID and Password boxes and then clicks OK.
If a message appears, informing you that you do not have rights to this operation, your user account has not been granted the "Completed Procedure, Enter" security right. To have a user with permission temporarily override this restriction so you can chart a completed procedure this one time, do the following:
On the message, click Yes.
In the Password - Completed Procedure, Enter dialog box, the overriding user enters his or her credentials in the User ID and Password boxes and then clicks OK.
If the procedure requires the selection of surfaces, and if you skipped either the selection of surfaces in step 4 or the entering of surfaces in step 3 or 5, complete step 4 to select the applicable surfaces.
If a certain global setting has been enabled, the Enter Required Procedure Fields dialog box appears. Verify or change any of the information that will be used for certain required fields.
Note: If you click Cancel, the completed procedure will not be posted.
Do the following:
Verify or change any of the following information that will be used for certain required fields:
Encounter Number - If a certain global setting has been enabled, this option is available. To specify an encounter number, do one of the following:
Enter an encounter number (numeric or alphanumeric, depending on a certain global setting).
Select an encounter number (if the applicable global setting is enabled).
Note: Depending on a certain global setting, the number may have to be unique for each patient, for each day, or for each patient per day.
Clinic - By default, the clinic that you are currently logged in to is selected, but you can select a different clinic. To change the clinic, do the following:
Click the search button .
The Select Clinic dialog box appears.
Note: If your user account has been granted the "View All Patients" security right for the Central clinic, the ID and name of all clinics appear in the list; otherwise, the ID and name of each clinic for which your user account has been granted the "My Clinics, View" security right (in the "Practice/Clinic Setup" category) appear in the list; however, if your user account has not been granted that right to any clinic, only the ID and name of the clinic that you are currently logged in to appear in the list.
In the list, select the correct clinic.
Click OK.
Provider - By default, default chart provider is selected, but you can select a different provider. To change the provider, do the following:
Click the search button .
The Select Provider dialog box appears.
Either leave the ID and Last Name boxes empty to get a list of all providers, or enter all or part of a provider's ID or last name in the ID or Last Name box, respectively, to search for a provider.
Under Search By, select one of the following options: This Clinic, to search for the provider in the clinic that you are currently logged in to; All Clinics, to search for the provider in all clinics; or My Clinics, to search for the provider in the clinics to which you have been granted the "My Clinics, Select Provider " security right.
Notes:
The All Clinics option is available only if your user account has been granted the "View All Providers" security right for the Central clinic and if your user account has not been granted the "My Clinics, Select Provider" security right for the clinic that you are currently logged in to.
The My Clinics option is available only if your user account has been granted the "My Clinics, Select Provider" security right for at least one clinic and if your user account has not been granted the "View All Providers" security right for the Central clinic.
Either select the All Providers option to include providers who are associated with clinics (and who have a Log On User ID), or select the In ApptBook option to include providers who have been set up in Appointment Book.
Click the search button .
The matching primary and secondary providers appear in the list.
Select the correct provider.
Click OK.
Instructor - If a certain global setting has been enabled, this option is available.
Click OK.
If the procedure has been set up to be for an implantable device, the New Patient Medical Alert(s) dialog box appears. Set up the options to attach the device to the procedure.
Do the following:
To add the UDI (if known), next to the UDI box, click Add UDI to search for the implantable device in the public, online Global Unique Device Identification Database (GUDID), which is maintained by the Food and Drug Administration (FDA).
Note: You do not change any of the other options in the Edit Patient Implantable Device dialog box that are already populated with data from the GUDID if the device is found.
In the Description box, leave the default description, or enter a brief description of the device as you want it to appear in the Medical Alerts window.
Set up any other options (if known) as needed. The following options are available:
Discovery Date - Enter the date that you found out about the device. By default, the current date is entered.
Area - Enter the area where the device is implanted.
GMDN PT Name - If known, enter the Global Medical Device Nomenclature (GMDN) Preferred Term (PT) name of the device.
Lot/Batch - If known, enter the lot or batch number of the device.
Serial # - If known, enter the serial number of the device.
Distinct ID - If known, enter the catalog reference number of the device.
Expiration Date - If known, enter the expiration date of the device.
Manufacturing Date - If known, enter the date that the device was made.
Device Attributes:
Brand - If known, enter the brand name of the device.
Version/Model # - If known, enter the version or model number of the device.
Company - If known, enter the name of the company who made the device.
MRI Safety Status - If known, enter the safety rating of the device for use in or near a Magnetic Resonance Imaging (MRI) environment.
Labeled as containing NRL - If known, select or clear the checkbox to indicate if the device is labeled as containing natural rubber latex (NRL).
Notes - Enter any notes regarding the implantable device.
To check the spelling of the note, click the Check Spelling button . This button is available only if a certain preference setting has been enabled.
Click OK to attach the device to the procedure.
The procedure is added to the graphical chart (if a charting symbol is used in conjunction with the posted procedure) and to the progress notes.
Notes:
Completed treatment that you post in Chart also appears in Ledger, and the applicable charges are listed on the patient's account.
Procedures that are flagged for medical cross-coding can now be cross coded in Chart or Ledger.
If a procedure has been completed for a patient, and you try to add another completed procedure with the same code for that patient on the same day, a message may appear and ask you to confirm that you want to proceed. Also, if your user account has not been granted the "Complete Duplicate Procedure" security right, a dialog box appears, and a user with permission must enter his or her credentials to complete the procedure. The Possible Duplicate Procedure warning message will appear under the following circumstances:
When you attempt to post a completed procedure that is not for a specific tooth (for example, a D0274), and that procedure has already been completed for the selected patient on the same day.
When you attempt to post a completed procedure for a specific tooth (for example, a D3310 on tooth 7), and that procedure for the same tooth has already been completed for the selected patient on the same day.
When you attempt to post a completed procedure with one or more surfaces of a specific tooth (for example, a D2150 on the distal and lingual surfaces of tooth 2), and that procedure for the same surfaces of the same tooth has already been completed for the selected patient on the same day.