Hi Gregory,
I just sign off my notes after I enter the icd9s and my comments. I do not enter cpts or do billing with AC. I am currently in a contract with a billing service that is satisfactory for me.
As much as I wanted to be a purist and stay paperless, I have had to go to a paper flowsheet/encounter sheet. I also had trouble keeping track of nursing care. To solve that we have gone to having 2 notes- a doc note and nurse note for each encounter.
Two encounter sheets for each visit are made and placed on a clipboard the day before-they have the pt name, a place for chief complaint, vitals (we lost a lot of notes at first and couldn't recover vitals), and check for pending labs, xrays, er visits, etc. The bottom part of my sheet is a grid that I put in cpt and associated icd9s.
The nurse encounter sheet is exactly like mine, except they do not record the vitals on their sheet. They use their sheet for all the clia waived tests, injections, vaccinations, etc that they do. They put the cpt and appropriate icds on the sheet. They also document these procedures in their note. They then send the note to me to sign off.
The nurse checks chief complaint, vitals, reconciles med list, and does any pending labs and has previous lab results on the clipboard before I go in the room.
I give my encounter sheet to the nurse after each visit. They staple them together at the end of the day. We then enter all the billing the next morning.
This works well for us. I hope you find a system that works well for you. We also have the vitals and labs on paper in case there is a problem saving the note for one reason or another.
