Quick question along these lines: How are you guys adding Vaccines (both the vaccine type and the administration fee) to the chart in the first place?

In our office the doctor verbally orders the MA to administer vaccines. The MA adds it to the chart via the Decision Support window. After doing that, to my understanding, AC only logs it into the Summary Sheet under vaccines but it does NOT add anything in the note. If the Dr. does not type this into the chart later then it is left out of the encounter note.

Since we do not use any billing features in AC we don't look at what is automatically added to the superbill. But out of curiosity in case we use the billing section one day, how would the CPT codes and Dx codes be generated? Does the Dr. have to create an order while he is charting?


Josue
Tampa, FL