• Careville Home
  • Instinct.vet
  • Pick The Brain Articles
  • Instinct Emergencies

Hello, How Can We Help You?

Instinct EMR
Navigation
Back To TopicsEMR User Guides
  • Account Deposits, Account Credits, & Unapplied Payments Guide
  • EMR Health/Service Reminders Guide
  • Username and Passwords
  • Taxes, Non-taxable Sales, and Discounts Report
  • Transaction Details Report
  • Transaction Summary Report
  • Standalone Patient Documents
  • Open Invoices Report
  • Incomplete Charts Report
  • Accounts Receivable (A/R) Summary Report
  • EMR Vaccine Reminders Guide
  • EMR PDF Label Printing Guide
  • Provider Summary and Details Analytic Reports
  • EMR Financials and Account Ledger Guide
  • EMR Analytics Guide
  • EMR End of Day Processing Guide
  • EMR Discounts Guide
  • EMR Invoice Guide
  • EMR Refunds and Returns Guide
  • EMR Taxes Guide
  • Invoice Closing
  • EMR Integrations Reference Guide
  • Asteris Integration
  • Cubex Integration
  • Heska Point-Of-Care Diagnostics Integration
  • IDEXX Diagnostic Integration
  • EMR Controlled Substance Report
  • EMR Gravity Text/Link To Pay
  • Merging and Transfers Guide
  • EMR Administrator Guide
  • EMR Business Office Guide
  • EMR Reference Guide
  • EMR Charting Guide
  • Rapid Registration
  • EMR Anesthesia (Ax) Mode
  • Outage Guidelines
  • EMR Rounds/Case Review Guide
  • EMR Drawing Block Guide
  • Task List User Guide
  • User Roles and Permissions Guide
  • EMR Student/Draft Mode Guide
  • EMR Appointment & Event Calendars
  • EMR Estimate Guide
  • EMR Prescription Guide
  • EMR DYMO Integration with Web Connect Service Guide
  • EMR Shareville Guide
  • EMR Shareville rVet Guide
  • EMR Comm Log User Guide
  • EMR Referrer Guide
  • EMR Gravity Payments User Guide
  • EMR Inventory Guide
  • Outpatient and ER Workup Guide
  • Common Hospitalization Workflows
  • Ordering, Charging, & Changing Fluids, Additives, and CRI's
  • Maintaining Instinct
  • How Instinct EMR Captures Charges
  • Streamlining Charges - Instinct EMR Tips and Guidelines
  • Dictation Programs in Instinct
Analytic Reports
  • Taxes, Non-taxable Sales, and Discounts Report
  • Transaction Details Report
  • Transaction Summary Report
  • Open Invoices Report
  • Incomplete Charts Report
  • Accounts Receivable (A/R) Summary Report
  • Provider Summary and Details Analytic Reports
  • EMR Controlled Substance Report
EMR Training Videos, Quizzes & Webinars
  • Instinct Academy
  • EMR Training Guide Quizzes
  • EMR Training Video: Appointment & Event Calendars
  • EMR Ax Mode Training Video
  • Instinct EMR Reference Video
EMR ProTips
  • Provider Commissions Reporting in Instinct
  • Filters/Sorting Guide
  • Insulin Therapy Guide
  • Snippets
  • Routine Maintenance of Instinct
  • EMR Product Groups
  • How does Instinct EMR handle Daylight Saving Time?
  • How do I set up an on-the-way patient in EMR?
  • How Do I Print In Instinct EMR?
  • Alerts Guide
  • Patient Safety Warnings For Chemotherapy Medications
  • What is an EMR Superuser?
  • Reopening a Visit/Treatment Sheet
  • How do I copy/paste Vitals in EMR?
  • EMR Assign To Me
  • EMR Invoice Tags
  • EMR ID System
  • 24 Hour Treatment View
  • Status Board not showing all patients
  • How do I mark a patient as deceased?
  • How do I skip or not complete a treatment?
  • Common OP/IP Product Groups
  • How do I record vitals if the patient isn’t due for them now?
  • Differences between Optional q1h Frequency, Every 1h, PRN, and UC
  • How do I view a previous Tx Sheet or download/print a Tx Sheet?
  • Communication Tools in Instinct
  • Weight Calculator (optional)
  • Advanced Patient Search
  • Handy Keyboard Shortcuts
  • Adding order notes, call parameters, or specific instructions to a treatment
  • Do orders reschedule automatically if I complete a treatment before/after the scheduled time?
  • Copy All Medications
  • Viewing Discontinued Medications
  • Other/Miscellaneous orders
  • Accessing Plumb's Drug Formulary in EMR
  • How do I exit full screen so I can minimize Instinct?
  • Multi-frequency orders using tabs
  • Using Emojis in Instinct
  • Vital Notes
  • How do I print a Tx Sheet?
  • How do I copy/paste vitals?
  • How Do I View or Change the Code Status?
  • Adding a One-Off treatment
  • Who Added, Changed, or Discontinued an Order?
  • Adding an Alert that doesn’t exist
  • TV Mode/Whiteboard User ID
  • How to access Instinct from a web browser
  • How do I put Instinct on a TV screen?
  • 'Instinct needs to authenticate your practice' message
  • How do I switch hospital locations?
  • I forgot/was never given a login PIN
  • Automatic Charges
  • Bulk Edit On Treatment Sheet
  • Can I change my PIN or login credentials?
  • Workflow Tags
  • How do I indicate other Patient Care Team Members?
  • Patient Safety Warning Systems
  • Triage Tags
  • How do I copy/paste from Instinct
  • How do I edit completed Vital entries?
  • How does My Board and pinning work?
  • How do I move the tx sheet if my patient was transferred to our other location?
  • Why is there no calculator for this medication order?
  • How to edit/delete a completed treatment
  • Creating/editing a Vital product
  • Viewing vitals from another visit or across a patient's lifetime
  • Why is there a money symbol next to some orders?
EMR Technology Guidelines
  • Routine Maintenance of Instinct
  • Instinct System Status
  • Hardware & Technology Guidelines
  • Installing Instinct on Home Computers
  • Internet & Power Outage Guidelines
EMR Release Updates
  • December 2022 EMR Release Updates
  • November 2022 EMR Release Updates
  • October 2022 EMR Release Updates
  • September 2022 EMR Release Updates
  • August 2022 EMR Release Updates
  • July 2022 EMR Release Updates
  • June 2022 EMR Release Updates
  • May 2022 EMR Release Updates
  • April 2022 EMR Release Updates
  • March 2022 EMR Release Updates
  • February 2022 EMR Release Updates
  • January 2022 EMR Release Updates
  • December 2021 EMR Release Updates
  • November 2021 EMR Release Updates
  • October 2021 EMR Release Updates
  • September 2021 EMR Release Updates
  • August 2021 EMR Release Updates
EMR Onboarding Documents
  • EMR On-Site Go-Live Guide
  • What is an EMR Superuser?
  • EMR Virtual Go-Live Guide
  • Medical and Workflow Guidelines
EMR Charting Guide
Print

EMR Charting Guide

Learn how to create custom exam forms and quickly record patient information in the Charts section.


Table of Contents

Charts Screen and Cover Page Overview

Adding Charts

Import Document Update

Pinning Charts

Expanding the Chart Pane

Opening Two Charts Side-by-Side

Uploading Files to the Patient Chart

Standalone Patient Documents

Sharing Documents/Files via Shareville

Filters/Previous Documents

Using Charting Documents

Adding Snippets, Attachments

Completing/Signing Documents

Editing, Duplicating, and Voiding Documents

PDFs

Charting Template Building and Charts Admin

Permissions

Charting Quiz


💡 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.


🚨 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.


↔️ 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).

Voiding an uploaded Chart Document via 3-dot menu
Undo Void for a previously Voided Document via 3-dot menu

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.


🗃️ Standalone Patient Documents 

You can now upload and attach documents to a patient without having to check them in! You can also upload documents for a patient who has never been checked in to Instinct in preparation for future visits.

📓 Please Note:  Unlike previous document uploads, these uploads/attachments will be tied to the Patient, not a specific Visit.

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. 

📓 Please Note: Only the listed accepted file types can be uploaded as a Standalone Patient Document.

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

You can Void documents via the 3-dot menu in the Attachments section. 

Selecting Void will prompt a reason for voiding the document. 

Any Voided documents will automatically be hidden once voided if the Show Voided Items toggle is set to OFF. You can show voided documents with the Show Voided Items toggled ON.

If a document was voided by mistake you can always undo a void.

Selecting Undo Void will prompt a reason for undoing the void on the document. 

Printing or Emailing Standalone Patient Documents

Standalone Patient Documents 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 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.


🔨 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.


🧠Test your knowledge with our Careville Quiz!


CONTACT US

Instinct Science
54 East Oakland Ave
Doylestown, PA 18901
sayhi@instinct.vet
866.267.1818
GET ON OUR LIST TESTIMONIALS PRIVACY & TERMS
ABOUT JOIN US INVESTORS
Made with 🧡 in Philadelphia
© 2023 Instinct Science, LLC
Instinct System Status
  • Careville Home
  • Instinct.vet
  • Pick The Brain Articles
  • Instinct Emergencies
 

Loading Comments...