In Section 2 of this course, we reviewed the manual method of encounter documentation. We will now use Document Skeletons to quickly and accurately generate the same documentation for us.
In the following article, we will run through an example of how simply choosing a diagnosis code during an encounter can trigger multiple document skeletons that present the provider with virtually all the documentation she will need to complete the encounter.
NOTE: In this example, the ICD-10 code we assign to the encounter has been set to trigger the document skeletons shown in the Verify Document Skeleton window screenshot below. Your own clinic's automations will depend on the specific set of document skeletons and triggers that have been set up for you.
- We begin our documentation once again by first selecting at least one diagnosis code. (If you add multiple diagnosis codes, all associated document skeletons will be presented to you for verification.)
- Next, in the Document Skeletons section of the chart, click Verify.
This will open a Verify Document Skeleton window, which displays all of the current document skeletons this provider has for this specific ICD-10 code.
These skeletons have been designed to keep the number of items displayed to a minimum, while still allowing you to easily tailor the documentation for a specific encounter.
There are three categories of skeletons that may be presented depending on which skeletons were triggered.
First are documentation skeletons. These skeletons contain the basic documentation that is necessary for this diagnosis, such as symptoms and symptom modifiers, physical exams, and so on.
Next are billing skeletons. Generally, these are used for primary CPT code and code modifiers for the encounter, but can accommodate any billable CPT code. In addition to documenting CPT codes, we have designed these billing skeletons to include a specific set of physical exams needed to qualify for the billing code. So, when any of these billing codes are added, we can be sure that the correct physical exams will come with it.
The third section contains treatment order skeletons. Here we have a variety of orders to choose from, allowing the physician to pick the best options for this encounter. Each of these treatment skeletons is also set up with a corresponding CPT code, if available. So we can be sure every time this order is added, the billing code will be documented, as well.
Longer lists of orders can be filtered by selecting an order type.
- Select all the necessary skeletons for documenting this encounter and click Confirm or Confirm & Start NobleDoc. This will generate the encounter documentation.
Before we learn about NobleDoc, let's take a look at the patient chart to see the results of importing our document skeletons.
If we navigate to the Vital Signs and Physical Exams tab, we can see all of the information that was generated for us.
Physical exams include normal and abnormal values as designed by the document skeleton.
Navigating to the Treatment Plan tab reveals the follow up appointments, medications, labs, and imaging orders that were generated for us.
The Billing code tab displays the ICD-10 code we added earlier in the document skeletons, along with the billing codes that were attached to our treatment order skeletons.
With our encounter documentation now accurately generated, we are ready to review and finalize the documentation using NobleDoc.
4. Click Start NobleDoc - Finalize Encounter.