Wiki Electronic Medical Record Guidelines for Multiple Services Sameday

[PAMELAJEAN]

The Urology practice that I code for has recently gone on electronic medical records. In the paper chart when a patient had multiple services sameday (ie whether it be cystoscopy,xrays,prostate biopsy)they would create a separate written report for each with a pre and post op diagnosis as well as a description of the procedure performed and results that they would sign. The physicians wonder what is appropriate in the electric medical record world? Can they have one encounter note for the visit with a separate heading and dictation for each procedure performed or do they need a separate encounter note documented with a descriptor heading of that note(such as cystoscopy,prostate biopsy,etc) and then the separate dictated note for each service? They are most interested to hear how others approach this.