Creating the Note
- Select the Note tab to see the completed note.
- The heading of the note contains all the necessary information about the clinic, the patient, and the encounter.
- Each section of the encounter is represented in the Note from Chief Complaint to Rx with additional sections for Return Appointment, E & M Code, Quality Measure Codes, and Counseling Time.
- The Narrative for History of Present Illness is generated automatically based on the provider’s selection during the encounter. The Radekal natural language generation creates an accurate account of the patient information using solid NLP technology to eliminate the need for dictation and transcription. Verbal annotation can be added using any commercial voice-to-text application such as Dragon Naturally Speaking. Additional annotations can be typed into the note before it is signed.
- The electronic signature will be added when the Note is signed. The signature can be uploaded through the Admin module or the Docpad Home page.
- Review the Note to make sure it reflects everything that was done during the encounter.
- Reimbursement for an encounter will reflect the completion of a thorough examination and complete and accurate coding.
- Notice the very top of the Note page includes tabs for Note (the current view below) and Charges (see below).
- Change Code indicates in red that there is no E & M coding so select this button to complete the coding process.
- Every patient encounter requires an E & M code. Click the Change Code button at the top of the Note to launch this window. Select the MDM code appropriate for the examination performed.
- Click Medical Decision Making for the three areas:Choose the level from Minimal to High.
- Diagnosis & Rx Opinions
- Data Complexity
- Risk to Patient.
- Choose whether this is an Established or New patient if it has not already been entered.
- Click on the Time area to add additional time to the Medical Decision Making code.
- To Override the code given, select the Override button and a window will appear with the additional codes. Make sure that these changes are reasonable and accurate to avoid the potential for audits.
- Notice that the applicable Quality Measures Codes are also listed on the right side.
- The image below shows the page when the coding is complete.
- Once all areas are completed, click Done.
- Review the Charges to ensure all the charges are correct before sending them to Billing.
- The Charges page shows the E & M code that was selected, the CPT codes, DX linkage and the Diagnoses.
- When all the codes and charges are correct, sign the note and the charges are sent to billing for payment.