Learn how to create custom exam forms and quickly record patient information in the Charts section.
Table of Contents
💡 ProTip: For more information regarding charts and records, check out this awesome Pick The Brain article: 10 Common Questions About Veterinary Medical Recordkeeping Standards
✍️ Charts Screen and Cover Page Overview
The Charts section (accessed at the top of any patient page) includes a helpful Cover Page spanning the history of the patient’s visits. It also includes easy access to all medical records, such as physical exam forms, discharge instructions, SOAPs, consent forms and other custom-built forms by your admin team.
As seen above, the top of the Cover Page includes Main Problem/DX and Account Patients sections. The Visit section below that is referred to as a Visit Card (more on this section below).
Main Problem/DX – This running list is part of the patient medical record where you can add a problem or diagnosis at any time by clicking ‘+ Add Problem/Dx’. When a problem is added to a checked in patient, it will appear within the current visit. When a problem is added to a checked out patient, it will appear within the last active Visit Card.
Keep in mind you can add, edit, resolve, unresolve, void, and reorder items at any time. If you resolve a Problem/Dx, it moves to the bottom of the list with a timestamp of the current date (see ‘anaphylaxis’ in the screenshot above).
To reorder the MPL, simply use the slider icon located to the left of the diagnosis to effortlessly drag and reorder your list.
The Main Problem/DX list can also be added to Charts templates by use of a Snippet, either ‘Active’ or ‘All’ (which includes active and resolved) problems. This Snippet is labeled MPL (Main Problem List).
Account Patients List – All patients listed under the client’s Account appear within this list. If multiple patients exist, you may click the patient name to navigate to that patient’s Charts screen.
Visit Cards – Visits are organized into ‘Cards’ and display the following from top to bottom in the screenshot below:
- Duration (hours or days)
- Reason for Visit
- Invoice Total
- Patient/Visit Alerts
- Notes/Belongings
- Chart Documents
- ‘Go to Visit’ button
- Check In/Out date and time (when applicable)
- Main Problems/DX
Full Record Download – Lastly, a ‘Print Record’ button is available at the bottom of the Charts screen to download/print records. Using the check boxes, you can easily select which documents to include in the full record download.
➕ Adding Charts
Type the name of a document into the Documents search box and select a document template (created by your hospital Admins). Clicking on a document template creates a new document for that patient’s visit and appears as a side pane on the right side of the screen. This will stay open until you close it.
The dropdown menu will show your most frequently used Chart document templates at the top. Each logged-in user will have a unique sort order, so your list will be personalized based on the Charts you use most frequently.
🚨 Import Document Update
Instinct does not support collaborative editing (such as Google Drive) meaning only one person can edit a chart document at a time. If two staff members are attempting to edit a chart at the same time, the first person making edits will be able to continue editing. The second person will see an error appear that states “Import Document Update” and will be unable to edit any chart fields. In order to continue editing, you must click on the ‘Import Document Update’ to import any changes from the first person.
📌 Pinning Charts
When opening a document pane, it is pinned by default—staying on the screen and allowing you to freely navigate the different sections of Instinct without having to search for this document to enter information.
⚠ Pinned Panel Warnings
Enhanced patient safety through eye-catching banners at the top of pinned panels (Chart, Comm Log, and RX) helps to eliminate any confusion while switching between patients.
A grey warning will appear when viewing patient A’s pinned panel but navigating away from patient A’s chart to other areas of Instinct.
A yellow warning will display when viewing patient A’s pinned panel in patient B’s chart.
📤 Full Screen Chart Editor
To open the Chart in full screen mode, simply click the Move to Full Screen icon at the top right of the panel.
Once in full screen mode, you can go back to the 1/4 panel display by clicking Move to Panel. Clicking Save and Close will save the document and exit out of full screen mode, taking you back to the patient’s Chart screen.
🗂 Opening Two Charts Side-by-Side
Clicking an additional document on the Charts screen will display two 1/4 panels side by side, though you can only pin 1 document at a time. The arrow icon can also be used to easily switch which document is pinned to the right hand side.
If you have multiple panels open, and click Move to Full Screen on one of them, the second panel will pin itself to the right hand side for easy multitasking.
📥 Uploading Files to the Patient Chart
Files such as referral records, diagnostic result forms, or a previous vaccine history can be uploaded to the Visit or Patient Attachments section by dragging/dropping onto the document screen or using the ‘Drag/Click to Upload’ button.
You can also edit the file name/type when uploading a new document. The rVet Sharing toggle will default as ON. If you don’t wish to share a document to the referring veterinarian, simply move the toggle to the left OFF position.
If a document was mistakenly uploaded to a patient file, clicking the 3-dot menu to the left of the upload gives you the option to ‘Void’. This won’t delete the document, but it will automatically filter it to hidden, and voided documents will not be accessible via Shareville, nor will they automatically send with a full record download.
You can also ‘Undo Void’ for a previously Voided Document via the 3-dot menu (you’ll want to toggle ‘Hide Voided’ OFF within the Filters first so this is visible).
Please keep in mind that files must be under 100mb. Accepted file types are .txt, .pdf, .docx, .xlsx, .zip, .png, .jpg, .gif, .mp4, .h264, .h265, .mp3, .mp4, .m4a, .aac, .mpeg, .wav, .dcm. The length of the file name should not impact the upload process.
To view an uploaded document, simply click on the document name and the file will automatically open a media preview for a quick look at the document contents.
Left ◀ and right ▶ icons help you effortlessly navigate through the uploaded attachments in patient attachments or all of the uploaded documents in the individual visit.
If you’d like to open the file outside of Instinct, simply click on the download 🔽 icon in the open preview window.
Or select Download in the 3-dot menu next to the document.
Audio and video file preview is supported in the Chrome Browser only, and Dicom image files are currently not supported for media preview.
🗃️ Patient Attachments
You can also upload and attach documents to a patient without having to check them in, as well as upload documents for a patient who has never been checked in to Instinct in preparation for future visits.
New Patients Without Previous Visits
The 3-dot menu next to the patient’s name allows you to Check In, Schedule Appointments, view the Patient’s Chart, access the Patient’s Comm Log, and Upload Attachments as a Standalone Patient Document before appointments/visits even without a previous check-in.
The Chart screen will be visible for patients who have never been checked into Instinct, however all other navigation tabs will be grayed out until the patient’s first check-in. You can upload Attachments as a Standalone Patient Document or edit details in the Patient Info Bar.
Checked Out Patients With Previous Visits
You can Upload Attachments as a Standalone Patient Document before appointments/visits on existing Patients even when they’re checked out.
Checked In Patients
Clicking on Upload Attachment in a checked-in patient’s 3-dot menu allows you to upload an Attachment into that Patient’s Chart as a Standalone Patient Document.
Uploading & Attaching Documents
You can upload documents by dragging/dropping onto the document screen or using the ‘Drag/Click to Upload’ button.
Only the listed accepted file types can be uploaded as a Patient Attachment.
The Document Label and Type are required, but the Source field is optional.
Clicking the 3-dot menu next to the document and selecting View, opens the document in the right window panel allowing you to edit the document Type or or add the Source within 24 hours of upload.
Void/Undo Void
Additionally, you can Void documents via the 3-dot menu in the Attachments section. If a document was voided by mistake you can always undo a void.
Printing or Emailing Patient Attachments
Patient Attachments will be listed at the top of the options to Print Record or to email from the Comm Log. PDFs and common image files are the only file types that will display as options. All other file types are not supported to be emailed or printed.
🔄 Sharing Documents/Files via Shareville (optional)
Shareville is a helpful portal where referring veterinarians can get automatic email notifications and review patient documents on demand as they are completed. Please note, Shareville must be enabled at your clinic by contacting us at support@instinct.vet. Once enabled, Shareville automatically notifies the referring veterinarian on file via email whenever one of their patients has Checked-In or Checked-Out of Instinct.
Admin Users can set up Chart templates to be available in Shareville by Default once completed, simply by using the drop down box shown below:
Available means this document won’t send to the rVet portal automatically, but users will be able to turn on sharing once this document is completed for a patient.
Automatically On means that this document will automatically go to the rVet portal when completed, though this can still be turned off at the patient and document level.
Never Allow means there will be no option to share this document in the portal for any patient.
For Available and Automatically On selections, you can toggle rVet sharing on/off at the bottom of the completed chart:
You can also click the Shareville button at the bottom of the main Charts screen to manually resend the initial ‘Check In’ email if a referring veterinarian was not selected at the time of Check-In.
See at a glance if a chart is shared on the Shareville portal with the rVet column.
- Shared items will display an orange dot
- Documents that have not been shared will display a gray dot
- ‘In Progress’ documents will not display a dot until they’ve been Completed
Documents set to ‘Never Allow’ for rVet sharing in Chart Admin will not display a dot and the rVet Sharing Toggle will be disabled.
Interested in learning more about Shareville? Check out our Shareville User Guide for Instinct hospitals and specific rVet Shareville Guide that can be shared with your referring veterinarians!
🔍 Filter and Search Documents
Use the Search Bar or the Filters to find and view specific documents. Voided documents will be hidden by default, but this filter can be cleared if desired. Previous documents are also organized by visit date and can always be viewed by clicking ‘Go To Visit’ on the charts screen.
📂 Using Charting Documents
When started, charting documents start as a status of ‘In Progress’. They can remain that way (and editable) for as long as needed. Once completed, documents are ready for signature (if set up that way, see below). From there they move to the status of Completed or Signed. More about document statuses can be found below.
Just like other parts of Instinct, all typing will autosave so you can feel safe typing and closing the side rail window and when you open it again, all of your information will be there waiting for you.
When starting to work on a Charting Document, if the treatment sheet has a doctor assigned, the doctor will automatically be assigned to this new document. If the treatment sheet does not have a doctor assigned, the doctor field will be blank and will need to be selected before it can be completed.
➕ Adding Snippets, Attachments
As you fill out the various fields of a Charting Document, there is a Snippets button which allows quick insertion of default text or canned responses. These can be set up by your Admin team to help fill out information in any notes field. To add a Snippet to a document, click inside a note box and the snippets icon will appear below the box (in addition to rich text formatting options including Bold, Italics, and Underline).
In addition to custom built Snippets, you also have the option to insert a patient’s vitals from their current treatment sheet, including:
- Vitals snapshot: intake (inserts the patient’s intake vitals for the current visit)
- Vitals snapshot: SOAP (inserts the patient’s most recent 5 entries of weight, TPR, and ins/outs for the current visit)
- Vitals snapshot: latest (inserts the patient’s latest vitals for the current visit)
- Vitals snapshot: all (inserts all the patient’s vitals for the current visit)
- Treatments snapshot: all (inserts the patient’s treatment list for the current visit)
- And many more!
Attachments, such as a previous history or patient images, can be uploaded to documents via the Attachments section at the bottom of the document pane. To view, simply click the black arrow to download/print.
✍️ Completing/Signing Documents
When all required fields are filled out and a doctor is assigned to the document, the form can then be marked as Completed. You can also adjust the time this document was Completed using the dropdown to the left of the ‘Complete’ button.
Completed documents are available to sign via ‘Sign’ button at the bottom of the document pane located at the right side of the screen.
Once the ‘Sign’ button is clicked, a signature box will appear, and the client can type their name into the signature box. The client must also check the terms checkbox before completing the signature which is required for legality.
After the signature has been completed, the bottom of the document pane will include the client name, signature, time of signature, checkbox confirmation (I approve this document), and the user witness (user logged in at the time of the signature completion). Please note that once a document has been signed, you may only leave an addendum and cannot void or edit the document.
If needed, document templates can also require multiple signatures. This is set up in the ‘Permissions’ section of the Admin screen.
✏️ Editing, Duplicating, and Voiding Documents
Use the 3-dot menu to Edit, Duplicate, Discard, or Void any In-Progress document.
Edit a document via 3-dot menu or clicking anywhere on the document row to open the side rail.
Duplicate helps you start a new document from a previous document so you don’t have to copy/paste certain fields that may have stayed the same (vaccine status, current medications, etc.). Please note you can always edit all fields when duplicating a document.
Discard is only available briefly upon initially selecting the chart for those cases where you accidentally chose the wrong chart template.
Void a document if you no longer want it to appear in the patient Charts screen. As a reminder, voided documents can be viewed via 3-dot menu and you can always undo a void.
🖨 PDFs
Completed and Signed documents can be exported as PDFs from the 3-dot menu on the charts screen and directly from the document panel. Documents that are still In Progress cannot be exported as a PDF until they are marked as Complete.
🔨 Charting Template Building and Charts Admin
Admin users will have access to the Charts and Snippets screens via the Admin menu to create, edit, duplicate, and discard medical record templates and snippets. If you are an Admin user, please check out our EMR Administration Guide for details!
✅ Permissions
📓 Please Note: The following ‘Permissions’ section is for hospitals/universities who utilize our student/draft mode.
All Instinct users have access to create new documents for patients on the charts screen. Any users who cannot complete treatments, such as a ‘Student’ or ‘Draft’ user role with the ‘create_draft_orders permission’, can only create draft documents and mark as a ‘Completed Draft’.
Similar to ‘Student’ or ‘Draft’ roles when ordering treatments, a separate user with the ‘approve_draft_orders permission’ can then approve draft documents which would complete the document and be available to sign.
Please keep in mind that if a student/draft role edits a completed document within 24 hours of it being completed, they will only have the complete draft option available. This document will need to be approved again by a user with approval permissions before it can be marked as complete.
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