How To Create a Chart Note

Modified on Sun, 18 May at 3:52 PM

GuardianMD EMR

How to Create a Chart Note

This guide provides step-by-step instructions for entering a charting note into the GuardianMD Electronic Medical Record (EMR) system. Chart notes are essential for documenting patient encounters, clinical observations, treatments, and care plans.

Steps to Create a Charting Note

1. Access the Patient’s Profile

Note: If the patient is not already in the EMR, use the "Add New Patient" button to enter their information manually.

Navigate to the Patients tab.

Select the desired patient by clicking on their name.

2. Navigate to the New Note Section

Click on the New Note section in the patient’s profile.

3. Start Charting

Collapse Sections using the eyeball icon to improve visibility!

Begin by entering the Visit Reason and Chief Complaint.

Patient History Tabs Explained

Medical

This section is used for a visit-specific narrative (entered in a free text field inside the note), and does not carry over to future notes.

Allergies & Current Medications

Both of these tabs pull information stored in their respective tab on the left-side navigation bar.

HPI (History of Present Illness)

Because this note won’t be automatically saved in ongoing records, it should provide enough detail to fully understand the client’s current status and treatment plan without relying on prior notes.

Quick Add Section Explained

Forms

Use the eyeball icon to view consent forms.
Forms can also be printed and uploaded later via the Documents tab.

Medications

Search and add prescribed medications.
Fill in required fields: request, start/end dates, quantity, measure, and units.
Important: Click “Add” at the bottom to save.

Allergies

Add patient allergies in this tab.

Vitals

Vaccines

Record vaccines administered during the visit.
Search the vaccine and fill in relevant fields.

Diagnosis

Add diagnosis codes to support the visit reason.
Important for billing, compliance, and documentation.

4. Notes Section

Manually create the note or select a note template from the dropdown (e.g., “G IV Therapy”)

After selecting a template, fill it out in the new tab that appears.

Once completed, click the “Add” button at the bottom to save.

4. Finalizing your note

Click the “Save and Sign Off” button in the bottom-right corner.

A pop-up will appear to let you select which forms to include in the chart note. Select your desired options and click “Add”.

Review the final note and click “Save and Sign Off” again.

If you experience any issues or need additional support, please contact our team at emrsupport@guardianmd.com for assistance.