The Dilemma:The Dilemma:To Close or Finalize?

The Discussion

• The difference between “Close” and “Finalize” 

• Setup preferences• Completing the exam• Addendums

 

Close or Finalize-The Dilemma

If I Finalize, the record cannot be

edited

Close or Finalize-The Dilemma

If I don’t Finalize the record can be

edited

Close or Finalize-The Dilemma

Calm down…it’s ok. You should do both.

Setup Preferences

Setup Preferences

The Finalize Button

Think “Finished”

What do you want to do next?

Where does it go?

Chart Audit-Start at Quicklist

ExamWRITER Patient ExamWRITER Patient Control CenterControl Center

1. Check to make certain that the exam was assigned to the correct Provider.

2. Were previous exams finalized? In this example, only one was finalized; the others were closed.

3. Double-click on the exam to open it.

Reason for VisitReason for Visit 1. Is the Technician’s name

listed?

2. Is there a PCP listed?

3. Other doctor?

4. Was an auto-letter printed to appropriate care-givers?

5.Is the occupation listed?

Chief Complaint/HPIChief Complaint/HPI 1. Is there an adequate chief

complaint listed?

2. Is the chief complaint based on a recall from a previous visit?

3. Is there an HPI listed?

4 Does the HPI have a minimum of 4 elements?

5. Are the Reason for Visit, Chief Complaint and History of Present Illness in agreement?

Patient HistoryPatient History 1. Check for:

Ocular, Medical, Systemic & Ocular Surgery, Systemic and Ocular Family History, Ocular & System Medications, and Social History

2. Is Spectacle and Contact lens history documented?

3. Has the doctor reviewed the history?

Review of SystemsReview of Systems

1. Is the ROS documented?

2. Is the documentation consistent with the Medical History and the Medications?

Vision-SpectaclesVision-Spectacles

1. Unaided and aided acuities listed?

2. Manifest documented?

3. Was Final Rx created?

4. Was Lab Order created?

ExaminationExamination 1. Dilation orders

documented?

2. CD ratio documented?

3. Goldmann eyedrop documented?

4. Abnormals removed from Normal list?

Special TestingSpecial Testing 1. Is Special Testing

documented?

2. I&R documented?

Impression/Plan/Impression/Plan/ManagementManagement 1. Are the Impression,

Plan and Management consistent with the Reason for Visit, Chief Complaint and History of Present Illness?

2. Is there an order for the patient to return to the office or be put on recall?

3. Electronic Signature?

CodingCoding 1. Are the Procedure &

Diagnosis codes (found at the bottom of the chart) accurate?

CodingCoding

1. Always use Quickcode when using 99 codes. In this example, it would be appropriate to bill a 99213.

2. In addition, it is helpful to use Quickcode to review elements of documentation when using 92 codes.

CodingCoding

1. Was the appropriate diagnosis linked to the appropriate procedure code?

Checking Lab Checking Lab OrdersOrders 1. To check whether the

patient ordered the eyewear or contact lenses from the lab order the doctor created,click on the Rx Orders icon.

2. Next choose from the drop down list either Eyewear, Hard Lens or Soft Lens.

Eyeglass OrderEyeglass Order 1. Did the patient order

eyewear from the lab order created by the doctor?

Note: in this example, the order states “Order Not

Billed”. This means that the patient did not

order the eyewear.

LedgerLedger 1. To view the Ledger,

Right-click on the blue Patient Toolbar and left-click on Ledger.

FinalizationFinalization 1. Finalizing a chart is an indication that it has been Reviewed thoroughly.  

2. Finalization of the chart should be completed on the day of the visit.

3. When the Chart Review is complete, click on the Finalization icon. The record will display with Close Record selected. Simply click on Finalize Record.

.

Batch Review

The chart is now Finalized

OOPS!

Addendums

Addendums

Addendums

You have learned…

• The difference between “Close” and “Finalize” 

• Setup preferences• Completing the exam• Addendums

 

Questions?