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Wiki Notes In EMR

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livininthegray

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We have recently turned on the coding function of our EMR and now our provider's only way to send a note to the coder is through email. Our previous coding system had the ability to add a note to the actual charge, but that note did not become a permanent record in the patients chart. Our providers are not happy about having to send a separate email and want to have a “notes” field added to the actual office visit/procedure note. This note field would become permanent on the actual office visit/procedure note.

For example; Dr. Vader scoped patient Luke Skywalker ID# 555 today. During his procedure he placed endo clips at two different sites. Please help us have two clips added to the PM system side.

I would like to know where I could find an “official” ruling on why these types of notes should not be added.
Does anyone know where I can locate this information?:eek:
 
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