By Dr. A. Carbonelle
Sometimes you will have a patient that will walk in to the clinic or call requesting an acute visit (Sometimes referred to as a TLC visit). It is up to provider discretion if you would like for these patients to be made nursing interventions or if you would like to get credit for a full appointment. Either way, prior to starting the note decide if you are going to have this patient complete a full visit or a nursing intervention and have your clerk make an encounter. Once you have the encounter made you can then open a note and link the note to it.
1. For nursing interventions:
Your nurse will do the billing, you can write a quick addendum with your assessment and plan onto their note, this gives the nurse credit but does not give the provider credit; this is best for minimal changes (i.e. BP recheck where you make one med change and your plan is to return to clinic in 1 month to review log)
2. For an acute visit
Have the clerk make an encounter, then link a regular ambulatory care note to that visit. The provider who is training you will assist you with making an acute visit template which is SOAP style. These visits do require a full set of vitals and it is an excellent opportunity to address any reminders that may be open. These are more appropriate for acute illnesses or acute pain visits.
***The important thing to remember is that you must have your clerk make an appointment before you can link any note because every nursing intervention and ambulatory care note must be linked to a visit for the providers to receive credit.
***Side Note: Administrative notes do not require an encounter however you do not get credit for these encounters, they should not be used when you are seeing a patient and should instead only be used when you’re doing administrative work, chart reviewing, etc.