Clinical Documentation & Supervision Protocol

🌐 Purpose 

This protocol outlines the standard operating procedure for clinical chart completion, compliance, and the supervisory review process for new providers at BESA Health.

🔑 Key Points

• Dx codes are required for all encounters. 
   
• When finished, save as status Save & Done to supervisor review until you have been cleared. 

✏️ Steps  

1. Note Generation & Content Standards

All clinical interactions must be documented using a standard SOAP (Subjective, Objective, Assessment, Plan) format, utilizing the Ambient AI scribe as the primary capture tool.

• Subjective & ROS: Ensure the history includes a relevant Review of Systems (ROS) tailored to the complexity of the presenting complaint.
• Objective & Physical Exam (PE): Document a focused, clinically relevant physical examination.
• Attestations: Every note must include the appropriate care-setting attestation at the top of the subjective section:
  • Telehealth: Use the standard BESA Telehealth Attestation (confirming patient identity, location, consent, and platform security).
  • In-Person: Use the standard BESA In-Person Attestation.

2. Coding, Orders, and Routing

Before moving a note to review or closure, complete the following technical steps within the EHR:

1. Diagnosis Coding: Click on +Diagnosis to add the specific, highest-specificity ICD-10 code(s) supporting the evaluation and management (E&M) level.
2. Orders: Ensure all relevant lab, imaging, or referral orders are explicitly placed and linked to the corresponding diagnosis.
3. Routing (Initial Months): Route the completed note to "Pending for Sign Off" to initiate the required supervisory review. Do not finalize or "wrap up" the chart during this onboarding window.

3. Collaborative Review & Sign-Off Workflow

Phase 1: Initial Supervised Period (Onboarding)

During your initial months, 100% of charts must pass through secondary review by the Supervising Physician.

[Provider: Complete SOAP + ICD-10] 

       └───> Route to "Pending for Sign Off"

                   └───> [Supervising MD Review]

                               ├─── Add Comments/Edits

                               └───> [Provider: Address Comments -> Final Sign-Off]

• The Supervising Physician will review the draft and add relevant notes, clinical pearls, or feedback directly into the chart.
• Action Required: Review the supervisor's comments. If clarification is needed, discuss them directly with the supervisor. Otherwise, apply the requested changes, make final updates, and sign off on the note.

Phase 2: Independent Sign-Off (Post-Clearance)

Once you receive formal clearance from the clinical leadership team indicating your initial review period has concluded:

• Immediate Completion: Complete your clinical charts independently and click "Wrap Up" to finalize and close the notes in real time.
• Quality Assurance: Following clearance, the Supervising Physician will transition to random chart audits on a monthly basis using the same clinical standards.
• Remediation: If systemic documentation or clinical gaps are identified during random audits, you will be formally notified to initiate a targeted remediation process.