I will agree w/ Bert about completing notes in the room.
I am FP, and see a lot of complicated pts, I can still complete all notes when in the room. I'm doing a lot of 99214's and some 215's. I can still complete the notes when in the room.
To top it off, I'm converting from paper to AC, and I'm entering a lot of data PMHX, FMHX, Med Lists, etc. I can still get it all unless rare circumstance.
The best way to ensure no lost notes, sign off at end of the visit.
However, if you are not able to sign off the note at end of visit. Please follow Bert's recommendation because I think this is the best test to figure it out. ***(I think the nurse is doing something wrong) Enter a few visits (or all visits) for one full day all by yourself, from start to finish. Forward them back to yourself and you should never lose any notes.
Try this and let us know what happens tomorrow.
