Selecting the appropriate note or visit type for each interaction in the patient chart is essential to provide a detailed record of actions taken in regard to a patient. 

Tips & Tricks

• Each note or visit type has an associated icon which is displayed in the note header for quick scanning of multiple collapsed notes.

Step by Step

• Navigate to the desired patient's chart

• Click on New Note to the right of the search bar

• A list of note types appear in the drop-down menu: 

  • Appointment: a scheduled visit with a single provider at a specified date and time.

  • Home Visit: a face-to-face encounter with a patient in a home environment.

  • Telehealth: an encounter with a patient via telephone or video.  This note visit type provides a link to the scheduled provider's virtual exam room within the note. 

  • Office Visit: a face-to-face encounter with the patient in a medical office setting. 

  • Lab Visit: a face-to-face encounter with the patient in a laboratory setting.  Usually to collect a specimen. 

  • Inpatient Visit: a face-to-face encounter with the patient in a hospital setting.  Inpatient visit notes can span from a single visit to multiple visits within a hospital admission.  

  • Phone Call: an encounter with the patient via phone.  Most commonly used for non-billable communications regarding the patient.

  • Chart Review: available to capture the interactions within the chart that is not part of an encounter with the patient

  • Letter: use previously created letter templates, or free text a letter to print for the patient.  Letters will automatically print with the clinic information and a signature if templated.

  • Message: use to securely send messages to the patient via the patient app.  The patient must have a verified contact method for a message note type to be available. 

Place of Service Code

Selecting the correct note type for a visit will ensure proper billing automatically adding the place of service code to the claim.

Resources

Video: Select Note Type