CPS Training Updated: 2/10/2019

AMB210 Chart Maintenance

Lesson 1. Chart Maintenance Overview

Chart maintenance refers to any changes a provider may make to a patient chart outside of a
scheduled office visit. A Clinical List Update encounter should be used to properly document
chart maintenance.

While there are more than three clinical lists in the chart (see image below), we will only focus
on the two most common clinical lists that need to be updated or edited during a medical
review:

1. Medications
2. Allergies

Screenshot 1. Chart Summary (showing default Clinical Lists)

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CPS Training and Learning Transformation
CPS Training Updated: 2/10/2019
AMB210 Chart Maintenance
A Clinical List Update is a type of encounter in CPS that is created using the New Document
process. It is recommended to use this encounter when you need to quickly add or change
data in different areas of a chart including clinical lists. For example, some providers use this
type of update to order labs or procedures ahead of time before a scheduled patient
appointment. This helps expedite the office visit and maximize the time the provider may
spend with the patient.

Screenshot 2. Clinical List Update Encounter (New Document)

Note: If you are not the provider but instead a member of the care team, after you finish
making a Clinical List Update, you must route it to the responsible provider for review and
sign-off.

Screenshot 3. End Update screen

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CPS Training and Learning Transformation
CPS Training Updated: 2/10/2019
AMB210 Chart Maintenance

Lesson 2. Start a New Clinical List Update Encounter

A New Clinical Update is a type of New Document. Follow the normal steps to create a new
document in CPS. Be sure to select Clinical List Update Encounter type.

1. Start a New Document

a. Open Chart
b. Select New Document
c. Select “Clinical List Update” encounter type
d. Leave your name in provider field (since you are creating this update)
e. Enter description in Summary field (medication review/CMR etc.)
f. Press OK

Screenshot 4. Update Chart Screen

Lesson 3. Update /Edit a Clinical List

Use the Clinical List Update encounter type to update or edit different parts of the chart
including clinical lists when necessary. For example, to add, change or remove a medication,
click medication button and make appropriate edits. Or to add, change or remove an allergy,
select allergy button etc.

1. Select desired clinical list (red buttons)

Screenshot 5. Clinical List Update Selection Buttons

2. Make the update or edit to the desired clinical list (New/Change/Remove)

3. Review “Effects of this update” field
4. Select OK or Cancel

Notes:
1. There are multiple clinical lists, however, when performing a comprehensive medical review,
the most common clinical lists you may need to update or edit are the medications or allergies
lists.
2. The system records and tracks all changes made by users.

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CPS Training and Learning Transformation
CPS Training Updated: 2/10/2019
AMB210 Chart Maintenance

Lesson 4. Route Update to Provider for Review and Sign-Off

When you are done making updates / edits to a clinical list, you must end your update and
route it to the responsible provider for review and sign-off.

1. End Update
a. Select End… button to end the update
b. Change Provider in Properties (add responsible provider name)
c. Route to Provider
d. Select Hold Document

Notes:
1. DO NOT select Sign Document (update).
2. You must route update to the responsible provider and select Hold Document.
3. When you change the provider name in the properties section of the End Update screen, the
system will automatically add the name you selected in the Route to section.
4. Any changes you make to a clinical list will not become permanent until after the responsible
provider reviews and signs-off on your update.

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