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Chart in OptiMantra

Mark OM, Support
Updated

 

Table of Contents:

Configure Charting Sections
Selecting Charting Sections
Starting a Chart Note
Data Pulling From Previous Notes
Patient Summary (Left Panel) 
Visit Details
Using Questionnaires
Visual Charting
More Commands and Chart Snapshots.
Quick Access Tools (Right Panel) 
FAQ
Additional resource

 

 

Legacy video: Chart in OptiMantra (legacy)

Configure Charting Sections

Before creating chart notes, you can configure the structure and sections of your chart. These sections are dual purpose and any of the subjective sections such as the ROS and lifestyle questions can also be sent to the patient as an intake form.

  1. Navigate to Settings > Forms > Chart Note/Intake

Selecting Charting Sections

You will see various sections available depending on the modality you practice (e.g., acupuncture, primary care, massage therapy).

For each section you can choose whether it appears on:

  • Initial Consult forms
  • Follow-Up forms

Some sections are required and cannot be removed, such as:

  • Subjective
  • Objective
  • Assessment
  • Plan
  • General (for basic notes charting)

Reordering Sections

You can customize the order in which sections appear in your chart notes.

To reorder sections:

  1. Click and hold a section.
  2. Drag and drop it into the desired position.
  3. Scroll to the bottom of the page.
  4. Click Save Preferences.

You will then be prompted to choose:

  • Just My Profile – saves preferences only for you.
  • All Users (if available) – applies preferences to other users.

Starting a Chart Note

Chart notes can be created from the Patient Actions Menu, which is accessible from several areas within the system.

You will see three charting options.

  • Initial Consult Note: Full SOAP note plus any additional sections configured for initial consult notes.
  • Follow-Up Note: For subsequent visits. These notes also contain the full SOAP. However, they often contain fewer additional sections, depending on the preferences set in your form configuration.
  • Basic Note: The Basic Note is used for general documentation that does not require a full SOAP note, such as brief procedure notes, administrative notes, and quick documentation entries.

Charting History

All previous notes can be viewed and edited from the Charting History section

Data Pulling From Previous Notes

When creating a new chart note, certain sections may automatically populate with information from previous visits. 

This can be configured in Settings > Business > Provider Settings. You can choose:

  • Whether data pulls from your own charts only
  • Or from any practitioner in the clinic

*Please note we do not recommend this method if you offer more than one type of modality or service type.

 

Importing Older Data

If you need to reference notes beyond the most recent chart or offer multiple modalities:

  1. From within the chart note, click the History button on the upper grey toolbar.
  2. Use the three-dot menu to:
    • Import specific sections
    • Import all information from a previous chart.

Chart Tags

Chart tags (found at the bottom of your chart note) are a free type area to help you distinguish different modalities or services provided during that visit, such as:

  • Primary care
  • Acupuncture
  • Botox
  • Psychotherapy

You can quickly reference these tags within the charting history to help ensure the correct data pulls forward for the relevant modality.

Patient Summary (Left Panel)

Several tools appear on the left side of the chart as well as within the patients dashboard for all staff to reference. 

Sticky Notes

  • Used for quick-reference information, great for FYIs or relationship building items.

Patient Tags

  • Used to label or categorize the patient. 

Medications & Supplements

  • Review and maintain the patients active and past medication and supplement history. 

Diagnosis

  • Review patients diagnosis history. This area will automatically update once you have added their ICDs to the assessment section of the note. 

Clinical Profile

  • Review and maintain the patient's allergies, as well as their personal and family medical history area.

*Patients will have the ability to maintain and update their clinical profile and meds & supplements on their patient portal. 

Visit Details

At the top of the chart note you will see:

Date of Service

Defaults to the current date but should be updated if charting after the visit date.

Location

Defaults to the patient’s primary location, but can be changed if necessary.

Visit Type Selector

Used to identify the general type of patient interaction 

Examples:

  • In-office visit
  • Telemedicine
  • Email consultation

FAQ: 

Can I customize the list of Visit Types? No, we would recommend you use the Chart Tags to supplement this. Chart Tags are clearly visible in the Charting History. 

Using Questionnaires

Questionnaires can automatically populate chart sections. If the patient has completed a questionnaire prior to the visit this button will be flagged with a red number. To review or complete a form: 

  1. Open the Questionnaires button.
    1. You can then fill a questionnaire or,
    2. Review a completed questionnaire, or,
    3. Select the the appropriate letter to drop the patients responses into the chart note ex. S button to insert questionnaire responses into the Subjective section. This will also total any scored forms.

If you use scored forms such as the PHQ-9 or GAD-7 from the 3 blue action dots you can view trends of the individual questions or the form total. 

If used, the intake button, allows you to import patient intake responses into the appropriate sections of the chart.

Visual Charting

The Visual tool allows you to document symptoms visually for spine and body points, a great resource for body work practitioners.

This tool can assist you with generating your subjective, objective, and assessment notes. 

More Commands and Chart Snapshots

The More Commands menu allows you to perform additional actions, including:

  • Generating tasks
  • Viewing growth charts
  • Accessing chart snapshots

Chart Snapshots (Autosave)

OptiMantra automatically creates chart snapshots:

  • When the chart is saved
  • Every 10 minutes while the chart is open

Snapshots include:

  • A timestamp
  • The data file size

If you want more frequent snapshots, simply click Save manually.

Quick Access Tools (Right Panel)

The right side of the chart provides quick access to related items.

 

1.Documents

Selecting Documents opens attached files (such as PDFs).

From here you can:

  • Zoom and review documents
  • Scroll through pages
  • Email or fax the document if needed


2.Tasks

Selecting Tasks opens the task screen where you can:

  • Edit tasks
  • Update task status

3.Lab Orders and Results

  • Clicking a requisition displays the lab order.
  • Clicking results opens the results view first.
  • You can switch back to the requisition as needed.
  • Results can be expanded into full screen.

FAQ

Q: Can I add hyperlinks into the Treatment Plan for patients?
A: Yes. In order to do so, you should use the text editor More Rich button > Insert Link buttons to do so or the link will not be clickable.

 

Additional resources:

See this article for more information on charting templates setup and usage: 

Set up and use Clinical Charting Templates (SOAP, Clickable and Dot-Phrase)

Manage Access Control for Charting

Growth Charts in your Charting

Additional Charting Articles

 

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