MA Checklist: End of Visit

1. Review progress note and procedure note(s) (Forms)
• Is everything documented properly?
• All assessments have plans associated with them
• Are they the correct plans?
• There is no erroneous information in the note like “Finding #1”
• Did you apply a Normal Exam to your visit?
2. Does your HPI make sense?
• All complaints are documented
• Do you have 2/2 green coding dots for this section?
3. Did you reconcile the patient’s information?
• Make sure the "R" icon in the sidebar of the progress note is no longer blue
4. Review the body map
• Each treatment plan should have a location marked on the body map
• If the provider performed a procedure such as a biopsy/excision, did you apply it to the body map? Did you place the path order from Inbox > Performed and assign it to a lab?
5. Photos
• Did you take photos of any problems that you want displayed on the note?
6. Coding
• Is all of the coding correct for what occurred during the visit?
• Do you have full coding (green dots) in the HPI and History?
7. EZ Check-Out
• eRX: Make sure all prescriptions were electronically sent to the pharmacy or printed for the patient
• Follow-up: Was a follow-up documented for the front desk (if needed) in the A&P?
• MACRA: Make sure you addressed available Quality measures (some may have to be addressed at a later time when pathology results are received)
• Consents: Make sure the patient signed all appropriate consents
• Suggested Products: Make sure you added all products you want to suggest to the patient to their Cart
• Cart: You can verify approximately how much the patient owes for today’s visit by checking the Cart
• Checked Out: Make sure to click Check Out to change the appointment status (this will move the patient into the provider's Incomplete Notes folder, so do not mark the patient Checked Out if there is still work to be done on the note)

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