Provider Resource Center

Provider expectations

• Documentation must support the reason for the encounter, diagnoses selected, services performed, and medical necessity.
• Complete and sign encounters timely so claims are not delayed.
• Ensure ordered testing, screenings, procedures, vaccines, and injectable medications are supported in the note.
• Use the appropriate TNC or Medicare note template when applicable.
• Review diagnoses and procedure selections before finalizing the encounter.

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Documentation standard

• Avoid generalized ROS documentation such as “Review all” or simply “Negative.”
• Address the systems relevant to the patient's presentation and services provided.
• Document sufficient detail to support the clinical picture and medical necessity.
• Ensure templated language reflects what was actually assessed during the visit.

Before finalizing the visit

• Determine whether a new Medicare patient is newly enrolled and whether a Welcome to Medicare visit is appropriate.
• Complete the required preventive components and screenings for the visit type.
• Use the appropriate Medicare note template whenever applicable.
• Document separately identifiable problems addressed in addition to preventive services when applicable.

Provider standard

• Do not automatically complete PHQ-9 and GAD-7 at every visit.
• Generally complete once annually when appropriate unless clinically indicated or otherwise directed.
• When performed for a mental-health concern, ensure documentation and diagnosis coding appropriately support the screening.
• Review the result and incorporate clinically relevant findings into the assessment and plan.

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Document

• The reason for testing and relevant symptoms.
• An appropriate supporting diagnosis.
• The specific test performed and result when applicable.
• The provider's clinical interpretation and plan.

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Provider documentation

• Document the medication, vaccine, or injectable product administered.
• Document the administration and clinical reason for the service.
• When applicable, billing must include both the medication/product and the administration.
• Ensure the diagnosis and documentation support the service performed.

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Every note should clearly support

• The reason for the encounter.
• Relevant history and clinical findings.
• The assessment and status of each condition addressed.
• Clinical decision-making and medical necessity.
• Medication changes, orders, referrals, and procedures.
• Patient education and follow-up instructions.
• The diagnosis and procedure codes selected.

Provider expectations

• Use the approved TNC macro structure.
• Remove sections that do not apply.
• Update templated language to reflect the actual visit.
• Do not carry forward outdated or incorrect information.
• Use provider-specific or facility-approved short keys.
• Confirm assessment and plan are individualized.

Workflow

1. Use the AI scribe during the visit when appropriate.
2. Review all generated content for accuracy.
3. Remove unsupported, duplicated, or incorrect information.
4. Transfer approved content into the standard macro.
5. Confirm diagnoses, plan, orders, and follow-up.
6. Delete the temporary AI note after transfer.
7. Sign the final provider note.

Required before closing

Review each business day

• Unsigned and incomplete encounters.
• Assigned tasks and staff messages.
• Patient messages and refill requests.
• Laboratory and imaging results.
• Referral results and specialist records.
• Prior-authorization requests.
• Clinical documents requiring review or signature.

Good task communication includes

• The specific action requested.
• Relevant patient or clinical context.
• Priority or urgency.
• Assigned owner.
• Required completion date when applicable.
• Documentation of the outcome.

Provider responsibilities

• Review results promptly.
• Identify critical, urgent, and abnormal findings.
• Determine appropriate follow-up or treatment.
• Communicate results to the patient.
• Document communication attempts and outcome.
• Create orders, referrals, or repeat testing as needed.
• Close or acknowledge the result in RXNT.

Examples

• Duplicate encounters.
• Test or training encounters.
• Administrative encounters.
• Visits that did not occur.
• Approved no-charge services.

Provider review should confirm

• Current prescription and over-the-counter medications.
• Dose, route, and frequency.
• Medication adherence and patient-reported changes.
• Allergies and adverse reactions.
• Duplicate therapies or interactions.
• Medications discontinued during the visit.

Review as appropriate

• Annual wellness and preventive visit eligibility.
• Cancer-screening status.
• Immunization history.
• Depression and anxiety screening.
• Fall risk and cognitive screening.
• Diabetes, lipid, and cardiovascular risk monitoring.
• Age- and risk-appropriate counseling.

Common procedures

Document

• Clinical indication.
• Consent and timeout when applicable.
• Site, technique, medication, device, or supplies used.
• Findings and outcome.
• Patient tolerance.
• Aftercare and return precautions.
• Specimen handling when applicable.

Provider considerations

• Determine whether the patient has an emergency condition.
• Review available schedule and staffing.
• Confirm whether the concern is appropriate for clinic care.
• Provide emergency instructions when needed.
• Document triage advice or refusal of emergency services.
• Coordinate with front office before adding the appointment.

Confirm before prescribing

• Clear diagnosis and indication.
• Medication allergies and prior reactions.
• Drug interactions and duplicate therapy.
• Appropriate dose, route, frequency, and duration.
• Renal, hepatic, pregnancy, and age-related considerations.
• Required laboratory or clinical monitoring.
• Patient education and follow-up plan.

Before approving

• Confirm medication and requested dose.
• Review last visit and treatment plan.
• Confirm required labs or monitoring are current.
• Check for medication changes or contraindications.
• Determine whether an office visit is required.
• Document approval, denial, or bridge prescription.

Review as applicable

• Clinical indication and alternative treatments.
• State PDMP.
• Controlled-substance agreement.
• Risk assessment and treatment goals.
• Required urine drug screening.
• Early refill or lost-medication history.
• Concurrent controlled medications.
• Follow-up frequency and monitoring.

Provider documentation may need to include

• Diagnosis and clinical severity.
• Previous therapies attempted and outcome.
• Contraindications or intolerance.
• Relevant laboratory, imaging, or examination findings.
• Requested medication, dose, service, or procedure.
• Why the requested option is medically necessary.

Referral order should include

• Specific specialty or service requested.
• Diagnosis and clinical reason.
• Relevant history and findings.
• Urgency.
• Requested testing or consultation.
• Supporting records that should accompany the referral.

Provider review includes

• Specialist findings and recommendations.
• Medication or treatment changes.
• Testing or follow-up required.
• Whether the patient needs an appointment.
• Care-plan updates.
• Patient communication when appropriate.

Provider responsibilities

• Complete and sign the note.
• Select accurate diagnoses.
• Document services and procedures performed.
• Support medical necessity.
• Document medication, units, and administration details.
• Complete procedure notes when applicable.
• Resolve documentation queries promptly.

Documentation should reflect

• Number and complexity of problems addressed.
• Amount and complexity of data reviewed or analyzed.
• Risk of patient management.
• Total time when coding based on time.

Examples requiring immediate escalation

• Possible stroke or acute coronary syndrome.
• Severe respiratory distress.
• Anaphylaxis.
• Uncontrolled bleeding.
• Severe altered mental status.
• Imminent risk of harm to self or others.
• Any condition beyond the clinic’s capabilities.

Provider expectations

• Document information relevant to patient care.
• Use designated behavioral-health workflows when available.
• Avoid unnecessary disclosure of highly sensitive details.
• Follow applicable confidentiality and release requirements.
• Use crisis and safety documentation when indicated.
• Report privacy concerns immediately.