Charting Tips

Write better notes faster: use templates, keyboard shortcuts, the patient context panel, and a consistent documentation routine.

Charting is a daily reality for DPC clinicians. DPC Pro’s note editor is designed to reduce friction: structured SOAP sections, auto-save, patient context at your fingertips, and distraction-free mode when you need to focus. This page collects practical tips for making the most of these features.

For the complete note-writing reference, see Write Visit Notes.

---

Choose the Right Note Type

When creating a note, select the note type that matches the encounter. The type categorizes the note for later filtering and helps your team find relevant documentation quickly.

Note Type	When to Use
SOAP Note	Standard in-person visits
Progress Note	Follow-up visits for ongoing conditions
Phone Note	Phone consultations
Telehealth Note	Virtual video visits
Procedure Note	In-office procedures
Consultation Note	Specialist consultations or second opinions

When you start a note from a scheduled visit, the type is pre-suggested based on the visit type (for example, a telehealth visit suggests Telehealth Note). You can change it at any time before signing.

---

Use the Patient Context Panel

The note editor provides two context panels that reduce the need to navigate away while writing:

Left Sidebar (Patient Context)

Displays at a glance:

• Allergies: prominently highlighted; shows “NKDA” if none recorded
• Current medications: up to five entries
• Chronic conditions: displayed as labeled tags
• Surgical history: listed if recorded
• Primary provider: the assigned provider

Right Sidebar (Visit Context)

Shows:

• Linked visit details (type, date, time)
• Upcoming visits: next three scheduled
• Previous notes: five most recent, each clickable to open
• Active prescriptions: medication name, strength, dosage form
• Membership status: current plan and status

Review previous notes from the sidebar

Select any note in the right sidebar to open it in a new view. This is faster than navigating to the clinical notes list when you need to reference a prior encounter.

---

Write Efficiently

Document During the Visit

The most efficient approach is to start the note during the encounter. Open the note editor at the beginning of the visit and:

1. Enter the chief complaint as the patient describes it.
2. Fill in the Subjective section with symptoms and history in the patient’s words.
3. Record vitals and exam findings in Objective as you go.
4. Complete Assessment and Plan after the physical exam.

Auto-save captures your work every two minutes, so even if you are interrupted, your note is preserved.

Use Keyboard Shortcuts

Shortcut	Action
Ctrl+S / Cmd+S	Save manually
Ctrl+Shift+F / Cmd+Shift+F	Toggle distraction-free mode

Distraction-free mode hides the side panels and centers the SOAP editor, reducing visual noise when you need to concentrate on writing.

Keep Sections Focused

• Subjective: document what the patient tells you. Use their language. Include relevant history, onset, duration, and associated symptoms.
• Objective: stick to findings. Record vitals, exam results, and any lab or imaging data.
• Assessment: state your clinical impression. Attach ICD-10 codes for structured tracking.
• Plan: be specific about next steps. Include medications, referrals, lifestyle recommendations, and follow-up timing.

Each section uses an auto-growing text area, so write as much as needed without worrying about scrolling.

---

Record Vitals Effectively

1. In the Objective section, select Edit Vitals.
2. Enter values for the relevant fields:
   • Temperature (Fahrenheit)
   • Blood Pressure (systolic/diastolic)
   • Pulse (BPM)
   • Respiratory Rate
   • SpO2
   • Weight (kg) and Height (cm)
3. Save the vitals. They appear as a summary grid above the Objective text.

All fields are optional. Record only what is relevant to the encounter. Vitals are available after the note has been saved at least once.

---

Add Diagnosis Codes

1. In the Assessment section, select Add ICD-10 Code.
2. Type at least two characters. Search by code (e.g., J06) or description (e.g., hypertension).
3. Select the appropriate code from the results.
4. The code appears as a tag in the Assessment section.

You can add multiple codes and remove any by selecting the remove button on the tag.

Build a mental shortlist

For your most common diagnoses, memorize the ICD-10 prefixes (e.g., E11 for type 2 diabetes, I10 for essential hypertension, J06 for upper respiratory infection). This speeds up the search significantly.

---

Maintain Problem Lists and Medications

Keep the patient’s problem list and medication list current as part of your documentation routine:

• After each visit, check whether any new conditions should be added to the patient’s chronic conditions list.
• When prescribing, ensure the patient’s current medications list reflects the prescription.
• During annual physicals, do a full reconciliation of conditions and medications.

These lists appear in the note editor sidebar for every future visit, helping you and your colleagues make informed decisions.

For the full workflow, see Problem Lists and Medications.

---

Finalize Notes Promptly

Complete and Sign

1. When finished writing, select Mark Complete. This signals the note is ready for signing.
2. Review the full note, then select Sign Note.
3. Confirm with the checkbox: “I have reviewed this clinical note and confirm that it is complete and accurate.”

Amend When Needed

If you discover an error after signing:

1. Open the signed note.
2. Select Create Amendment.
3. Enter the reason for the amendment.
4. Edit the relevant sections and sign the amendment.

The original note is preserved unchanged. The amendment links to the original with a clear audit trail.

See Write Visit Notes for the complete amendment workflow.

Sign before the end of the day

Unsigned notes can pile up. Whether you sign after each visit or in a batch at the end of the day, aim to have all notes signed by the time you log off. Unsigned notes from days ago are harder to finalize accurately.

---

Related Pages

• Quick Start for Clinicians: getting started
• Daily Clinical Workflow: your daily routine
• Reviewing AI Suggestions: working with AI drafts
• Patient Timeline: using the timeline during visits
• Write Visit Notes: complete note reference
• Problem Lists and Medications: managing conditions and prescriptions

Need Help?

If you run into issues with charting, reach out to the DPC Pro support team at [email protected] or visit the troubleshooting guide.