Charting

Articles

View Prior Notes While Charting a Visit
Learn ways to view prior Visit Notes while charting a visit.
Start a Patient Visit
Learn the steps that Clinical Staff and Providers take to start a new Visit Note.
Enter Vital Signs and Growth Measurements
Learn how to enter Vitals, other measurements, and Growth Info, and view Growth Charts and prior Growth Measurements.
Encounter: Document Chief Complaint, History of Present Illness, and Review of Systems
Learn how to document a patient's Chief Complaint (CC), History of Present Illness (HPI), and Review of Systems (ROS) in an Encounter Note.
Well Visit: Document Interval History and Review of Systems (ROS)
Learn how to document the patient's Well Visit to address their overall health and changes since their last visit.
Layer Templates
Learn how to layer Templates while charting a Visit.
Enter a Patient's History
Learn how to enter Medical, Family, Social, and Newborn history, plus their Birth Info and Maternal/Pregnancy info. Learn, too, how to add custom History questions and add History to the Problem List.
Enter a Patient's Allergies and Reactions
Learn how to enter and/or review a patient's Medication and Non-medication Allergies from within a Visit Note.
Complete a Patient's Risk Assessment
Learn how to review a patient's Risk Factors and update, as needed.
Well Visit: Document Developmental Milestones
Learn how to document Developmental Milestones as narrative or as graphical chronology.
Asthma Action Plan Wizard
Learn how to create an Asthma Action Plan.
Document the Physical Exam
Learn how to document a Detailed Exam (Encounter or Well Visit) and a Narrative Exam (Encounter only).
Chart an Encounter with a Well Visit
Learn how to document an Encounter while charting a Well Visit.
Well Visit: Document Anticipatory Guidance (AG) and Counseling
Learn how to document the Anticipatory Guidance and Counseling during a Well Visit.
Manage the Order Worksheet
Learn how to use the Order Worksheet from within a Patient Visit to order/create tasks for Meds, Labs, Imms, Pat Ed, Surveys, and other Follow-up items.
Medications Administered in the Office
Learn how to order and complete orders for medications to be administered in-office.
Save a Template When Charting
Learn how to save a Visit Template while charting a Visit.
Flag a Note as Incomplete
Learn how to flag a Note as incomplete to come back and finalize it at a later time.
Code and Finalize a Patient Visit Note
Learn the steps a Provider will take to code and finalize a Patient Visit.
Add and View Visit Note Addenda
Learn how to add an addendum to a Visit Note that has been finalized.
Invalidate a Finalized Encounter or Well Visit Note (Providers Only)
Learn how to invalidate an Encounter or Well Visit Note.
Print a Patient Exit Note
Learn how to print a Patient Exit Note for a finalized or unfinalized Visit Note.
Nurse Only Visits
Learn how to document a Nurse Only Visit.
Finalize Open Visit Notes from the Navigation Panel (Clinical Work)
Learn how to view all open and finalize all open Visit Notes from the Clinical Work window.
Cosign a Note
Learn the workflow to perform when a Mid-Level Provider requires a cosignature on Visit Notes.
OP Coding Decision Support
This article contains a collection of printable Quick Reference Guides.
The Importance of Finalizing Notes in a Timely Fashion
Learn Best Practice for finalizing Visit Notes in a timely manner.
How Charges Get to the Superbill
Learn the triggers that generate charges for a patient when documenting a visit.
Adding and Sorting DX Codes for Claims
Learn how Diagnosis Codes are added to and sorted on Claims.
Apply a Placeholder Template to a Visit Note (Split Go-Live)
Learn how to apply a Well Visit or Encounter placeholder template when the charting of a Visit is not done in OP.
Color Coding for Review of Systems
Learn what the ROS color coding means in Encounters and Well Visits.
Set a Default Exam Template
A default sick visit is helpful for providers who like to chart while in the room with the patient.
Using the HCPCS Level 2 Code 3008F for Pay for Performance (P4P)
Version 14.19 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 as...