Brown County Avatar User Guide Chapter 05 Outpatient Dictation Notes Updated 7/19/12

Transcription

1 Contents Chapter 05 Outpatient Dictation Notes... 2 Overview... 2 TRANSCRIBER PROCESSES... 3 Initial Entry of Outpatient Dictation Note... 3 Revision of Outpatient Dictation Note in Draft status... 6 Draft Note Completion if NOT billed (has never been sent to Co-Signor)... 6 Draft Note Completion if BILLED ( Final note has been rejected by Co-Signor and returned for revision)... 7 DICTATOR (AKA Co-Signor/Approver) PROCESSES... 8 Approval/Rejection of Note... 8 Review/Co-Sign Notes Screen... 9 VOID/REPLACEMENT OF APPROVED OUTPATIENT DICTATION NOTES Overview Determine If Billing Transaction Can Be Cancelled or Must Be Retained Void Progress Note Create Replacement Note (Either new billable note or Independent Non-Billable note) Attach Individual Notes to Existing Service PRINTING THE OUTPATIENT DICTATION NOTE FOR OUTSIDE ORGANIZATIONS Page 1 of 13

2 Chapter 05 Outpatient Dictation Notes Overview The Outpatient Dictation Note is a special type of Avatar Progress Note designed to streamline the handling of billable Outpatient Notes that are currently dictated into our Dictaphone system. Currently there are only two Note Types set up for this purpose: Medication Check and Psychiatric Evaluation. Other Note Types can be created and used via the same process, but they require additional configuration steps and testing to insure the service codes and notification steps (workflow) are in place. The Outpatient Dictation note works differently from other types of notes and dictated evaluations currently in use in other areas. In this document we will explain the process steps, the roles of the transcriber and dictator (AKA Co-Signor, Approver), when the billing transaction occurs, how to handle communication about changes and revisions, and when the document is locked from further revision and the dictator s electronic signature applied. Once approved by the Co-Signor, this note cannot be revised further and cannot have additional notes appended to it. If necessary the original note can be voided, unbilled, and re-created OR voided and a new independent note can be created and associated with the billing transaction. Page 2 of 13

3 TRANSCRIBER PROCESSES Initial Entry of Outpatient Dictation Note 1. Transcriber runs Avatar option Outpatient Dictation Note. 2. On Screen 1, fill in all items with Red heading. --The practitioner must be filled in under both Practitioner and user to send cosign to-do item to. --For Initial Entry of the note under Progress Note For always pick New Service. Independent Note is used only when creating a replacement for a voided note. --DO NOT do anything with the Select Draft Note to Edit box, that s used only for revisions (see Revision of Note in Draft Status) Page 3 of 13

4 3. On Screen 2, transcribe or (if the info has been typed into a Word document first) copy/paste the dictated info in the Notes Field. 4. If the transcriber is interrupted and unable to complete the note, or has questions to ask the dictator, select <Draft> and click <File Note>. --A reminder to-do item will be sent to the transcriber. --IMPORTANT-with this kind of note, there is no way for the transcriber to send a comment or question to the dictator automatically. This will have to be handled outside the system. 5. When the note is complete and ready to send to the Co-Signor (aka Approver/Dictator), --Select <Final> and click <File Note>. --IMPORTANT- Final at this stage simply means the note cannot be updated by the transcriber unless the Co-Signor rejects it. It does not mean the note is in its official final approval state including the Co-signor s electronic signature --IMPORTANT- if a note is accidentally sent to the Co-Signor before it s ready, the Transcriber must contact the Co-Signor immediately and have them reject it. ONCE THE CO-SIGNOR APPROVES THE NOTE, IT CANNOT BE REVISED FURTHER; IT WILL HAVE TO BE VOIDED AND A NEW INDEPENDENT NOTE CREATED AND ASSOCIATED WITH THE BILLING TRANSACTION. Page 4 of 13

5 -- A reminder to-do item will be sent to the Co-Signer. --The billing transaction for this service is generated at this point and is associated with the Note. Page 5 of 13

6 Revision of Outpatient Dictation Note in Draft status IMPORTANT-An Outpatient Dictation Note can be in Draft status for two reasons. It may need to be handled differently depending on the revisions that are needed. The transcriber didn t finish the note due to time constraints or because more info/clarification was needed from the dictator. In this scenario, the Billing transaction has NOT been created. The Co-Signor rejected it. In this scenario, the billing transaction has already been created. Draft Note Completion if NOT billed (has never been sent to Co-Signor) 1. Transcriber runs Avatar option Outpatient Dictation Note. 2. On Screen 1, --Fill in ONLY the Client and Episode. --Click on Select Draft Note to Edit box and you will see any notes for this client/episode currently in Draft status. --Choose the draft note to be completed and page 2 info will be filled in, proceed to Screen 2 3. On Screen 2, fill in the rest of the info and/or make revisions in the Notes Field. Page 6 of 13

7 4. The note can again be saved in Draft Status or Final Status. See step 4 and 5 in the Initial Creation section above. Draft Note Completion if BILLED ( Final note has been rejected by Co-Signor and returned for revision) In this scenario, the transcriber will have received a To-do item saying revisions are necessary. The Co-Signor must have communicated to the transcriber what changes need to be made, either via a comment attached to the rejection To-Do item, or through other means. The Co-Signor s rejection will have returned the note from Final to Draft status, making it available for the transcriber to edit. The transcriber s process to complete the draft note is the same as described above for an unbilled draft note. IMPORTANT-In this scenario, when the transcriber marks the not as Final and sends it to the Cosignor, billing occurred on the first go-round and no additional billing is generated. Page 7 of 13

8 DICTATOR (AKA Co-Signor/Approver) PROCESSES Approval/Rejection of Note To-Do List Notification 1. When the Dictator logs into Avatar they will see a message saying they have things in their To-Do list. 2. On the Avatar Home page, --single click on My To-Do List under TASKS the To Do List screen will be displayed with a line showing the date the To-Do was created. --double click on the date line they will see the info line shown below (client name/patid blacked out). --double click on the long info line and the Review/Cosign Notes screen will be displayed Page 8 of 13

9 Review/Co-Sign Notes Screen 1. Dictator reviews the document. NOTE-dictator can toggle to Chart Review by clicking on it at the bottom of this screen 2. If any changes need to be made to the body of the document, Dictator MUST reject the note (choose Approve Note=NO). --This will set the note status back to Draft and send a To-do to the Transcriber. --The Co-Signor s Comments box can be used to communicate changes required to the transcriber, but NOT TO MAKE ACTUAL CORRECTIONS. Corrections/Revisions must be done by the transcriber. -- The Co-Signor s Comments will NOT be included when the official hard-copy version is printed for outside distribution. --Optionally the changes can be communicated to the transcriber via , phone, or in person. 3. If the document is correct, approve the note by selecting Approve Note=YES --IMPORTANT-Once approved,the dictator s Electronic Signature is applied to the document and it cannot be revised in any way or have additional notes appended to it. --If necessary, it can be voided and a replacement note created. The process for doing this varies, depending on whether the billing transaction can be canceled or not. Page 9 of 13

10 VOID/REPLACEMENT OF APPROVED OUTPATIENT DICTATION NOTES Overview If an Outpatient Dictation Note that s been given final approval by the dictator/co-signor is found to be incorrect or incomplete, it cannot be unapproved or returned to Draft status. It must be voided (Avatar option Void Progress Note ) and a replacement note created. The process varies depending on whether the billing transaction can be caught and cancelled before it goes outside the system. Determine If Billing Transaction Can Be Cancelled or Must Be Retained If the billing transaction has not been transmitted to a payor, it can be cancelled and a new Billable Outpatient Dictation Note can be created generating a new service and billing transaction. If the billing transaction has already gone out, a new Independent (Non-Billable) Outpatient Dictation Note must be created and associated with the service/billing transaction. Void Progress Note Page 10 of 13

11 Create Replacement Note (Either new billable note or Independent Non-Billable note) If the billing transaction can be caught and cancelled by the billing department before it gets out into the big world, a new Outpatient Dictation Note can be created using the process described above under Initial Creation of Outpatient Dictation Note. If the billing transaction is already gone, an Independent Note (non-billable) must be created and associated with the existing billing transaction. The same Outpatient Dictation Note option is used as for the initial creation, but instead of New Service, choose Independent Note. It s filled out the same way, except Service Charge Code, Program, Location, and Duration are not used. Page 11 of 13

12 Attach Individual Notes to Existing Service IMPORTANT: This option is used ONLY if an Independent (non-billable) replacement note has been created. 1. Choose Client and Episode 2. Optionally you can filter the list of notes using the Start Date, End Date, and Note Type filters on the left bottom 3. Click on <Select Note To Attach>; a list of notes will be displayed. Click on the note you want to attach. 4. Under Link Note To choose Services (we are currently not attaching notes to appointments) 5. Optionally filter the list using the Start/End dates on the lower right. 6. Pull down the Appointment/Services list, select the correct service, and Submit. Page 12 of 13

13 PRINTING THE OUTPATIENT DICTATION NOTE FOR OUTSIDE ORGANIZATIONS To print this type of note in the approved format for outside organizations, they must be printed via the special option Outpatient Dictation Note-FORMATTED. User chooses client, episode, and if more than one note exists a list of possible notes to be printed is displayed. The document can be directed to a hard copy printer, converted to PDF for electronic distribution, or faxed directly if the user has a fax device enabled on their workstation. Page 13 of 13