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.

1. 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.
2. 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.
3. 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).
4. Don’t forget to include the details of contrast used, including units, if applicable.
5. 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.
6. 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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