Path: Smart Toolbar > Chart button > Encounters tab > Start New Note or Open Note button
This section will guide the user through the steps required to code a visit and finalize the note. This section is specific to the provider workflow.
- Select the Assess/Plan tab.
- Review the diagnosis code(s) for the visit in the Diagnoses section of the window.
|Select the checkbox in the Add PL column if the diagnosis should be added to the patient's problem list. Click the Yes or Yes + Details to confirm.|
- If you chose Yes, you are required to complete the entry in the Problem List at a later time.
- If you chose Yes + Details, the Problem List window opens to complete any additional information.
- Modify the codes when necessary. To add or modify ICD-10 codes, follow the steps below:
- Click the ICD-10 field that says 'Click here to add a new diagnosis code'.
- Begin typing a description of the diagnosis code in the ICD-10 Description column or enter the code itself in the ICD-10 column.
- Press the Enter key. The ICD-10 window displays.
- Select a code and click the Post Edit button.
If the code is not found:
- click the Full Search button.
- Select the Master radio button to open the Master list and/or select the Complete radio button. The ICD-10 Code table displays.
- Highlight the code.
- Click the Select button.
- Click the Post Edit button.
- Click the Coding tab and verify the Visit Type is correct. OP will always default to Established. If this is a New patient visit, select the correct radio button.
- Click the Use Suggested button, or select a code from the list above.
- To add additional CPT codes, follow the steps below:
|Note: CPT codes associated with the applied template will show in the lower pane of the window. Additional CPT codes can be added and will show in the visit note, but duplicated CPT codes will not pass to the electronic superbill. When appropriate, the units of a CPT Code can be modified here. If duplicated, CPT codes must be billed on separate claim lines, and your practice will need to develop a process for notifying your billers.|
- Click a Category button.
- Double-click a CPT code from the panel, repeat as necessary.
- Click the Lookup CPT button.
- Enter the CPT or Description.
- Click the Search button. The search will default to the Frequently used list of codes, but you may have to search the Complete List. To do so, click the 'Complete list' radio button.
- Double-click to add, repeat as necessary.
|Note: After all appropriate ICD-10 and CPT codes have been added to the visit, the user will want to assign the diagnosis codes to the corresponding procedure (CPT) codes.|
- Click the Summary button to review the note.
|Note: The Patient Exit Note will be created when the note is finalized. The following steps are optional if a printed Patient Exit Note is requested or required.|
- Click the Patient Exit Note tab.
- Click the Rebuild Summary button.
- Click the Note button to print.
|Note: The Note reviewed by field is optional. If the practice or state requires a percentage of notes charted by mid-levels or medical students to be reviewed, and the reviewer is visible on a note, click the drop-down arrow and select the reviewer.|
- Click the Finalize button to lock the note in it's current state. The Confirm window displays that asks if you are ready to finalize the note.
|Note: In the Staff Provider directory window, if the co-signature required checkbox is selected for the user, then the note is not locked down when this user finalizes the note. Notes can then be edited by the supervising provider. If the co-signature required is not selected in the Staff/Provider Directory window when the user finalizes the note, then the note will not appear on the supervisor's list to review.|
- Click the OK button if you are prepared to finalize the note, or click the Cancel button if you are not prepared to finalize the note.
|NOTE: If there wasn't a template available and you created this patient note from scratch, you may save it as a template by clicking on the Save as Template button. Once you click on Save As Template you will name the template, select the category where that template should appear, and then choose the sections that should be part of the template and save it by clicking on the OK button.|