Copy Note

Updated: 06/23/2023 | Views: 1800

Use the copy feature to duplicate an existing patient note using the same note type (e.g., SOAP). If copying to a different note type, use the SALT (Same As Last Time) feature to copy sections of an existing note into the new one.

Tebra recommends the following best practices when copying a note in the event an audit is conducted:

• Confirm that the copied note is an accurate documentation of the latest patient encounter and update any items that may no longer apply.
• Validate that the Evaluation and Management (E&M) code submitted is fully supported by the newly copied and edited note.
• Validate the diagnosis codes submitted with the claim; do not automatically utilize the same codes from the source note. Auditors monitor claims for recurring diagnosis codes for what is typically a “short-term” condition (flu, cold, rash, etc.). However, if the patient is still under treatment for this condition, do not hesitate to report the appropriate codes.
• Validate that any other procedure code(s) submitted was actually performed in the new encounter and not a result of the copied note.

Access Notes Enter the first 2–3 letters of the patient's name or date of birth (mm/dd/yyyy) in the top navigation bar search box. Click to select the patient from the auto-populated results. The patient's Facesheet page opens. Click Notes. The Notes page opens. Click Open or View. The Encounter Note page opens.
Copy Note Click Copy. The Duplicate Note Confirmation pop-up window opens. Click Ok to confirm. The duplicated note opens.
The current date and time displays in the copied note. Document or modify the note for the current visit, as applicable. Then, finalize the note as necessary.