Charting

Articles

OP Coding Decision Support
This article contains a collection of printable Quick Reference Guides.
The Importance of Finalizing Notes in a Timely Fashion
The Importance of Finalizing Notes in a Timely Fashion Sue Kressly, MD, FAAP Medical Director, OP Providers often ask me why it’s important to finalize notes in the EHR or what the industry standard is. There are four main reasons to fin...
Vital Signs and Growth Measurements
In this section you will find the steps to document the Primary and Secondary Vital Signs for the patient as well as the Growth Measurements.
How Charges Get to the Superbill
There are several triggers that generate charges for a patient when documenting a visit.
Using the HCPCS Level 2 Code 3008F for Pay for Performance (P4P)
Version 14.8 Overview Many users question how they can get more room on their well visit claims to report all of the pay for performance (P4P) items that the payer wants them to report. Consider the use of HCPCS level 2 code 3008F, "BMI ass...
Layering Templates
This article will show you how to layer templates. Additional templates can be applied when working from the the CC/HPI/ROS, Detailed Exam Tab. or the Assess/Plan Tab.
Invalidate a Finalized Encounter or Well Visit Note (Providers Only)
Version 14.8 Invalidate a Finalized Note It may be necessary to invalidate an encounter or well visit note in the event that it was erroneously entered.  To invalidate a finalized note: Click the Chart  button and locate the patient...
Save a Template When Charting
While working on a sick or well visit for a patient, you may realize how beneficial it may be to save this visit as a template. With the following steps you can quickly build up your template library
Charting a Sick Visit with a Well Visit
While conducting a Well Visit, the provider may find that he/she needs to incorporate a Sick encounter note for the same day.
Note Marked as Incomplete
Version 14.8 Overview There may be instances when a provider needs a visual reminder that an encounter or well visit note is incomplete. Prior to saving a note, an indicator can be set as this visual reminder to flag the note as incomplete. ...
Cosign a Note
Version 14.8 Overview If it is required that mid-level providers need a provider to cosign notes, then the steps below will complete this workflow. It is important to note that for any well or encounter visit which requires a cosignature, the mi...