Tips for Boosting Note Accuracy
Last updated September 27, 2025
During a conversation with a patient, there are certain ways you can talk to ensure higher accuracy and detail in the note:
- If this is a new patient or a returning patient, it is helpful to state this clearly at the beginning of the conversation for Level of Service coding
- During a physical examination, verbally state your findings out loud so they will be captured in the audio recording. For example:
- “Trendelenburg test is negative bilaterally” “External rotation of the right hip is at 30 degrees” “She has full flexion and is lacking negative 2 degrees of extension in the left knee” “Lift-off test is negative for the right and left” “Anterior Drawer, Lachman, valgus and varus stress test are all negative bilaterally” “Posterior internal rotation is to T12 on the left and T9 on the right”
- “Abduction” and “adduction” can sound similar at times. It may be helpful to spell it out, such as “A-Bduction” and “A-Dduction”
- Be sure to indicate which side you are talking about, i.e. “left” or “right”
- If the patient points at an area of tenderness but does not verbally state it, dictate out loud which area they are referring to, for example:
- “Tenderness to palpation in the anterior right hip” “She has left medial knee pain”
- If you review X-ray or MRI images, verbally state something such as, “let’s go ahead and review your MRI images” or “upon personal review of the patient’s X-ray images, I found” as this will impact the LOS code for the appointment
- During your assessment/plan discussion with the patient, clearly state the diagnosis, for example:
- “Based on the physical exam I believe you have [insert diagnosis here]” “I’m going to diagnose you with [insert diagnosis here]” “I suspect you have [insert primary diagnosis here] as well as [secondary diagnoses]”
- If you use the phrase “treatment options” or “plan” this will also aid in accurate capture in the “Assessment/Plan” section
- If you would like the patient to return for a follow-up, clearly state this and state when you would like them to return, such as:
- “I’ll see you again in 4 weeks” “I’d like you to return to see me again in 2 weeks” “We’ll follow-up in 8 weeks to touch base”
- If you have any remaining information that you would like to be captured in the note, but perhaps do not want to verbally say out loud while the patient is present, you may upload a separate dictation file to the patient and this information will be added to the note as well for that patient encounter.
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