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How are other practices documenting time with a patient that isn't for a face to face visit. For example, doing diabetic teaching over the phone, or care management meetings? Currently we use an addendum and tracked data. Are others making an encounter without adding vitals?

We use addendums at our office for those types of notes

Welcome to the Boards, Jennifer.

Like Marty, I use addenda for such notes. If you generate an encounter and don't enter vitals it will count against you for MU. Even if you're not doing MU, I find it helpful to reserve the encounter note for actual encounters.

We have developed a couple of templates for different types of addendum notes. I also find it helpful to use a consistent format for the addendum subject so that when I look at the list of my Past Encounters I can easily see what's what. "PC" for phone calls. "TC" for transition of care calls. "Update" for info I want to add to PMH/SH/FH at the next visit.

John

There are a couple of ways.

One is to use a message and save it to the chart. You can't bill it*, but then sometimes there is no need. (* not directly, you could open the account information and generate a bill but this is slow and tedious.)

Another is as above, using an addendum. This works well and will send you straight to billing.

I just want to expand on something Dr Howland toughed on, and that is doing an encounter without vitals will count against you for meaningful use. It actually all depends on if the patient has had another visit during the reporting period or not. The vitals measure counts unique patients for the denominator, which means that at least one visit during the reporting period must have height, weight, and BP recorded. If the same patient comes in a week later, you do not need to take vitals on the patient is it is not necessary.

What DOES count per visit is the clinical summaries. Those are tracked per visit, therefor could count against you if you are using the MRE to document all your encounters. Though with V7, doing the clinical summary has gotten easier with the "Declines Patient Summary" checkbox (check that box before forwarding the chart and you will get credit for clinical summaries).

That all being said, I think everyone here is correct in saying that addendums are the better way to document these type of encounters. Especially if you bill for these type of encounters.

Thanks Mark, that's useful information and adds to the reasons you should use addendum.

I did not know that you only needed vitals once during the reporting period. This is very helpful in understanding and working them.

Should we consider adding "decline summary" to addendum???

Not really needed, Wendell. Addendums do not count toward your MU numbers. You can add as many addendums as you want and it will not affect your numbers for any of the core and menu items.