SALT Note

Use the SALT (Same As Last Time) feature to copy sections of a previous note into a new one, regardless of note type. When the new note type is different than the one being copied, only sections that are common in both notes will be copied. If the duplicated note type is the same, users can use SALT or the copy feature to duplicate an existing patient note.

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.

A new clinical note can be created from three different locations: the patient's appointment on the Dashboard, the patient's Facesheet, and the Notes tab. It is recommended to create the note from the patient appointment to auto-populate appointment details.

Create Clinical Note Hover over the Platform icon and click on Dashboard. The Dashboard opens. Click the In Office tab. All patients with an in-office status displays. Click on the patient's appointment to view the appointment card. Click Create Clinical Note. The default note type opens. Note: If a clinical note for this appointment is in progress, the saved note opens. To select a different note type, click the drop-down arrow and select the note. Important Note: Clinical logs the user out after 15 minutes of inactivity and does not save new notes in progress. To avoid losing the new note and enable autosave, click Save & Close. Then, click Open to start documenting the clinical note.
SALT Note Click the SALT Note drop-down arrow and select a previous note to copy. The Duplicate Note Confirmation pop-up window opens. Click Ok to confirm. The duplicated note opens.
The appointment date and time displays in the copied note. Note: If the new note was not created from an appointment, the current date and time displays. Document or modify the note for the current visit, as applicable. Then, finalize the note as necessary. Note: If a different note type was used to SALT the note, it is recommended the copied sections are reviewed for accuracy.