Entering medications and vital signs enhances the system’s ability to generate more accurate clinical notes—including the physical exam, review of systems, and treatment plan. These inputs also help improve the accuracy of ICD and billing code suggestions.

You can add or update medications and vitals at any time. If the note has already been generated, click the large green Regenerate button at the top of the page to refresh the note with the updated information.

When charting an admission note, the system can also automatically include the patient’s medical, family, social, and surgical history. Relevant history may also be reflected in the treatment plan.

The system makes every effort to generate accurate ICD codes based on your documentation. However, occasional discrepancies may occur—especially when CMS updates or retires certain codes. Please review all ICD codes before submitting claims to ensure accuracy.

We are currently exploring partnerships with clearinghouses to support direct electronic claim submission. In the meantime, please download or print the completed note and submit it through your current process for billing private insurers, Medicare, or Medicaid.

For guidance on proper insurance billing procedures, please visit: CMS: Getting Started with Electronic Billing