Creating and completing session notes in AdvancedMD

Effective clinical documentation is essential for continuity of care, compliance, and ensuring timely payment. This article includes step-by-step guides and best practice tips for creating session notes in AdvancedMD. It will also touch on the required note fields and how to select the appropriate diagnosis. Note that session notes and charge slips must be completed in AdvancedMD, and cannot yet be completed in the Rula provider portal.

Clinical documentation at Rula

For timely biweekly payment processing, creating and signing your clinical documentation is essential. Please complete session notes and charge slips within 48 hours of appointments. You may view this interactive tutorial for how to complete a session note and charge slip from start to finish. 

Adhering to this best practice allows us to efficiently submit documentation on your behalf and ensure remittances every other Friday. View this article to learn more about clinical documentation requirements at Rula

Creating new session notes 

There are two ways to open a session note for an appointment in AdvancedMD, from the dashboard and from the timeline on the patient chart. Opening a session note in either of these two ways ensures that your note is linked to the correct appointment. If you’ve opened a session note that is not linked to the correct appointment, follow this tutorial to correct the error.

Opening a note from the Dashboard

  1. Log in to AdvancedMD
  2. Go to the Dashboard > double-click on the client’s appointment on the left-hand side.
    Screen_Shot_2022-11-23_at_5.01.05_PM.png
  3. The session note will then be generated and linked to that appointment 
  4. From here, you can select the note template to complete the note.

Opening a note from the Patient Chart

  1. Go to the patient timeline
  2. Look for the date of the scheduled appointment
  3. Click the three dots next to the appointment you are writing a note for
  4. Choose "Add Linked"
  5. Choose "Patient Note

Screen_Shot_2023-04-14_at_12.29.15_PM.png

  1. The session note will then be generated and linked to that appointment 
  2. From here, you can select the note template to complete the note.

Selecting a note template

Once you’ve opened the session note, you’ll select the appropriate note template for the session type. To learn more about and view samples of each note type, view our Sample Clinical Documentation library or visit the additional articles linked below. 

  • Select the note template from the dropdown
  • Be sure that the template type selected in AMDS_Mobile

  1. From here, you’ll fill out the note’s required fields
  2. Once the note is completed, sign the note using the sign-off password: 1234
  3. A charge slip will be automatically generated for billable sessions. Learn more about creating and signing a charge slip here.

Required Fields

  • Yellow fields on all note template types are required.
  • All notes must include a CPT code and Diagnosis Code
  • All notes must include a Location of service
    • For telehealth appointments, be sure to select the radio button next to “Telehealth (video or phone)” If this is missed, you may encounter a “services_provided_location” error when attempting to sign the note.
  • Session Start Time is the time the client joins your session.
  • Session End Time is the time your client leaves the session.
  • Any field with a small arrow to the right gives you the option to select multiple answers.

mceclip4.png

Selecting a Diagnosis

Watch this video or follow the step-by-step guidance below for more information on how to select a diagnosis.  View this article to learn more about diagnosis requirements and FAQs.

  • To add a diagnosis, click the ICD button below the diagnosis box.
  • Then, search for your diagnosis by typing in the code or description, or filter by Pick Lists > Behavioral Health.

mceclip5.png

  • Click on the relevant F code diagnosis for your client.
    • Note: Z and R codes are not billable diagnosis codes
  • Copy the code and diagnosis by clicking the two pieces of paper below “Copy” on the right-hand side of the row to ensure the diagnosis is entered in the Diagnosis box.
    mceclip6.png
  • Sign your note by clicking Sign at the top of the page > enter the sign-off password 1234 > Sign.
    mceclip7.png

Note: The passwords for electronically signing off on documentation in AdvancedMD are separate from your login credentials. To sign documentation in AdvancedMD, always use the following universal password: 1234

Additional Resources

  • Clinical Documentation articles - Here, you’ll find more detailed information and guidance on effectively completing the various types of documentation at Rula. 
  • Initial assessment step by step guide and FAQs - Step by step guides on how to complete initial assessments in Advanced MD as well as answers to FAQs for this type of documentation
  • Progress Notes Part One and Part Two - Watch these two videos to learn more about the elements of a quality progress note and view a step-by-step video of filling out a progress note.
  • Writing your notes while conducting a session - Information on how to open note and conduct a telehealth call simultaneously in AdvancedMD
  • Link multiple notes to a session - Detailed instructions on how to link multiple notes to the same appointment

Was this article helpful?

0 out of 0 found this helpful