23 Aug Six Tips & Tricks for Your Simulation Notes
Simulations are an integral part of the radiation process. Simulation documentation is relatively straightforward, but there are some pitfalls that we commonly see. Here are a few key items to remember when documenting simulations.
- Don’t forget the simulation order. Even though it does not represent a billable service, there must be a sim order in the chart. This can be included in another document, such as the E&M note or clinical treatment planning note.
- Make sure the diagnosis matches the treatment site. Quite often the diagnosis is carried forward from a previous document or from the chart diagnosis list, and it does not accurately reflect the area about to be treated.
- Make sure the note is specific to the patient. Checkboxes and forms may be used as long as there is ample space for narratives (and the narratives are filled out).
- Don’t forget to include the details of contrast used, including units, if applicable.
- The physician’s simulation note MUST be signed by the physician. If the therapist and physician share a simulation document it is appropriate for both to sign off if the EHR will allow it.
- Make sure all simulation documents match. If using separate therapist and physician documents make sure there are no discrepancies between them.
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