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 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 ‘abscess’ and ‘abdominal hernia’ in the screenshot above).
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 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.
📌 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.
↔️ Expanding the Chart Pane
To Expand the document pane, and make it easier to navigate, simply click the Expand button at the top right to make it wider.
The document will also collapse to its original size after it is closed. If you re-open the document to enter more information, simply click the Expand button again.
🗂 Opening Two Charts Side-by-Side
Clicking an additional document on the Charts screen will show 2 panes 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.
If you have multiple panes open, and Expand one of them, the second one will automatically close.
Conversely, if a pane is Expanded and you open a second one, the expanded document will automatically collapse to its original size.
📥 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 Documents section by dragging/dropping onto the document screen or using the ‘Drag/Click to Upload’ button.
If necessary, you can also edit the file name/type when uploading a new document. The rVet Sharing toggle will default as on. To avoid sending records back to the referring veterinarian, simply move the toggle to the left.
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 3-dot menu (you’ll want to toggle ‘Hide Voided’ 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. The length of the file name should not impact the upload process.
To download an attached document or file, simply click on the row and the file will automatically download to your computer.
🔄 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 checking the box as shown below:
If there are any documents you don’t want automatically share for every patient, you can leave this box unselected.
For documents that aren’t set to share by default, you can enable the rVetSharing toggle on the charts screen.
You can also click the ‘rVet Sharing’ button in 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.
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!
🔍 Filters/Previous Documents
Use the Filters to view specific documents by type or search by the document/file name. 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)
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.
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 (Print button) and directly from the document pane. Documents that are still In Progress cannot be exported as a PDF for security reasons.
To edit the header and footer information on any PDF document, please contact support@instinct.vet.
🔨 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.