Ruh's Charting Feature enables you to save, sign, and lock your charting notes. After a chart note has been locked, it can be edited solely through a Chart Note Addendum.
Additionally, locked charting notes receive a timestamp.
In order for a provider/therapist to Sign/Lock their own Charting Note, they need to have the correlating Permission for Charting enabled.
Charting Note Options
When editing a charting note, you'll notice a Save button on the top-right. While Ruh Care automatically saves your charting note, you can manually push the button to ensure your progress is saved.
Within the Save button, there is a drop-down selection with more Saving options:
Save and Close: therapist can save note only, returning to edit, sign, or lock at any time.
Sign Note: therapist can add a digital signature to the note.
Lock Note: therapist can lock note and prevent further edits, apart from addendums
Sign & Lock: therapist can add a digital signature and lock the note, preventing further edits apart from addendums.
Benefits of Locking Chart Notes
As an industry best practice, therapists can lock their chart notes after finalizing them, as a permanent record following a client session. The advantages of doing so, are to ensure that:
Once a chart note is considered final by the therapist, it is not subsequently modified
Other therapists & administrators in Ruh cannot write over or retroactively make edits to a charting session
Any updates needed to a Chart Note are logged separately as an addendum, and/or in some cases, as a New Updated Chart Note
Lock & Timestamp a Chart Note
To lock a chart note, navigate to the client's profile and either starts a new charting note, or edit an existing note.
Open/Edit a charting note
Select the drop-down option next to Save
Select Lock Note
Note: If required fields are in a Charting Template, then the therapist will be prompted to complete any missing required fields before the note can be locked.
Once locked, an indicator will appear, showing that the chart note is locked. A note cannot be edited further by any team member.
When other care team members view the charting note, they will see that it has been locked in the Chart Note History.
Add an Addendum to a Locked Chart Note
Once you've locked a chart note, you may not make any edits to the content of the note. However, you can add an addendum if there is additional information that needs to be added post-signing.
To add the addendum, navigate to the charting area of the client's profile and select the desired chart note. Click on the blue "View Note" button, and scroll to the bottom of the note.
From there, you can type and save the addendum so that it is attached to the previous content of the chart note. You will be able to see the date and time the original note was locked, as well as which therapist it was locked by (if you're working with another therapist).
Other Therapists Adding an Addendum
Multiple team members can add an addendum to a charting note.
To add an addendum to another therapist's note, an account admin will need to enable the following setting:
"Can write addendums to charting notes of other therapists."
The therapist must either be a Care Team member for the client or have permission to "View All Clients" across the organization in order to access charting for the client.
The therapist will see the Chart History section for the client and will be able to add an addendum accordingly.
Have a Team Member Review a Chart Note
One common utilization of charting addendums is to have a Supervisory therapist review a locked note and add an addendum that they have reviewed the note (with any comments they would like to add).
If you would like a specific therapist to be alerted to review a charting note, we recommend using Ruh's Task feature.
Create a task and assign it to the therapist.
Tag the client in the task, so the therapist knows which client the chart note refers to (clients are not notified, and do not see tasks).
Optionally, add a due date for the task and set a reminder for the task.
Optionally, set the task as high priority,
The therapist will be notified of the task, and see it in their pending tasks. They can check off to mark the task as complete.
Quick Tips
Save your charting note regularly using the "Save" button to ensure your progress is saved.
Locking a chart note ensures it cannot be modified, providing a permanent record of the client's session.
Supervisory therapists can review locked notes and add addendums to indicate their review. Use Ruh's Task feature to assign and track these reviews efficiently.