How-To Guides
Writing a Note
We offer a series of simplified templates to keep writing your clinical note simple.
When you need to write a note based on your visit, there’s a handful of ways to get started.
Writing a Note
Initiate Patient Check-In
When you are ready to see your patient, you may initiate the check-in process in three separate ways:
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Select “Check-in myself” from the Check-In Helper, which will appear at the top of every page until it’s taken care of.
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Select “Check-in” while hovering over the appointment on the calendar.
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Select “Check-in” in the Patient section of the facesheet.
Once you’re on the Check-In page, notes for any appointments the patient has that day will be displayed.
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Previously created notes for that day will say “Created” in the “Create?” column.
After clicking the “Create Note(s)” button, the note will be created, and you may navigate to it in the “Forms” section.
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Alternatively, if a Timely Billing Alert appears, you may select “Edit Note” to go directly to the note.
TIP: If you wish to create a note without an appointment on the calendar, select +Note from the Forms section of the Facesheet.
The most common note types will be the progress note options. However, there are other options such as groups, communication notes, History of Present Illness, etc.
If you have an activity like a phone call with a patient's other provider lasting up to an hour, which doesn't involve seeing the patient directly, you can select the 'Session Note' type. This will give you all the necessary billing codes to process such billable events.
Completing the Note
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Therapy session length: How much of the total appointment time was spent specifically on therapy with the patient. This auto-fills in the Billing section.
Input Tools
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Use the dictation tool to turn speech to text. (Enable Browser Microphone access)
Use autocomplete phrases for common observations
To use them quickly, just type in the short-hand code.
Use the copy forward function to quickly copy information from past notes into your assessment section.
Patient Vitals
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Use the vitals section to record the patient’s weight, height, and other important health information.
BMI is automatically calculated.
Percentiles will be auto-generated.
Mental Status Exam
Click “Normal” to auto-fill status quo observations.
Change inputs as necessary.
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Current Medications & Prescription Pad (Prescribers Only)
Type in the name of the prescription, and it will auto-suggest common drug types.
Problems
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Press “enter” to create a new line. Press the X icon to remove the current line.
Fill in the patient’s problems, and what type of problem it is.
Problem types include:
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Minor/Self-Limiting
New/Undiagnosed - Uncertain Prognosis
Acute - Uncomplicated
Acute - Systemic Symptoms
Acute - Harm Risk
Chronic - Stable
Chronic - Exacerbation, Progression or Side Effects
Chronic - SEVERE Exacerbation, Progression or SE
Chronic - Harm Risk
Diagnoses
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Add diagnoses by the code into the box. Remove diagnoses by clicking the X icon.
Billing
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The name of the patient’s insurance company will auto-fill in the “Plan” section.
Indicate “Place of Service” and “Delivery Method” in the dropdown menus.
“Therapy Minutes” will be based on what was entered at the top of the note in the “Therapy Session Length” section. “Total Minutes” indicates total session length.
Click “E&M Calc” under the “CPT Guidance” section to receive an assessment of how you might bill your appointment based on the content of your note.
If needed, specify “Medical Service” codes, “Psychotherapy (Prescriber Add-Ons)” and “Family Services”.
If you have already billed a CPT code for that same patient that day, you will receive a warning.
Workflow
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Specify if a note needs a second signer for a split session, or for a trainee supervisor to approve.
If you need to convert the appointment into a different form type, you may request to do so.
Once you’ve completed the note, click the “Sign” button to sign the note.
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An “Unsign Form” button will be available for 15 minutes after the note is signed if you need to make a quick change after signing the note.
If you need to add information after 15 minutes, you will need to write an Addendum.
