Welcome to your training

1What this job actually is

Think of yourself as a translator between two languages. The provider speaks clinical. Your job is to capture that clinical conversation accurately so the chart tells a clear, defensible story for the next provider, the family, the auditor, and the billing team.

2The three rules that matter most

3What a psych visit usually looks like

In SNF (skilled nursing) or ALF (assisted living), the provider often sees patients in their room or a small office. The patient may be elderly, have dementia, be medically complex, or too sedated to give a full history. That is normal and expected. The provider gathers info from four places at once:

4The daily rhythm

Before the visit

• Pull the patient list, sort by facility
• Skim each chart: last note, current meds, recent labs, new orders, incident reports
• Pre-populate the note shell: demographics, allergies, meds, problem list
• Flag anything unusual: new fall, new behavior, dose change, lab abnormality

During the visit

• Capture verbatim quotes when possible, in quotation marks
• Note the provider's questions and the patient's answers
• Write down med changes spoken out loud (drug, dose, frequency, rationale)
• Don't try to write the final note now. Just capture the data.

After the visit

• Draft the note using the right template
• Run an AI narration prompt with your captured data
• Self-check: does the note justify the billing code? SI/HI documented? Plan specific?
• Send to provider for review and signature

1Major neurocognitive disorder (Dementia)

Significant decline in memory, thinking, language, or judgment that interferes with daily life.

Common subtypes: Alzheimer's, vascular, Lewy body, frontotemporal, due to Parkinson's.

What to look for: MoCA or MMSE scores, neuroimaging, family report of progression, ADL/IADL decline.

ICD-10: F02.81 (with behavioral disturbance) or F02.80 (without).

2Major depressive disorder (MDD)

Two weeks or more of depressed mood or loss of interest, plus other symptoms (sleep, appetite, energy, concentration, guilt, psychomotor changes, suicidal thoughts).

What to look for: PHQ-9 score, sleep changes, appetite changes, weight loss, withdrawal, statements about worthlessness or wanting to die.

ICD-10: F32.x (single episode), F33.x (recurrent). The x is severity.

3Generalized anxiety disorder (GAD)

Excessive worry on most days for 6+ months, hard to control, with physical symptoms like restlessness, fatigue, muscle tension, sleep disturbance.

What to look for: GAD-7 score, somatic complaints without medical explanation, frequent calls to nursing for reassurance.

ICD-10: F41.1.

4Bipolar I and II disorder

Bipolar I: At least one manic episode (elevated/irritable mood, decreased need for sleep, grandiosity, pressured speech, risky behavior).

Bipolar II: At least one hypomanic episode plus at least one major depressive episode.

ICD-10: F31.x.

5Schizophrenia and schizoaffective disorder

Schizophrenia: Psychotic symptoms (hallucinations, delusions, disorganized thinking) for 6+ months.

Schizoaffective: Psychotic symptoms PLUS a major mood component.

ICD-10: F20.9 (schizophrenia), F25.x (schizoaffective).

6Delirium

Acute, fluctuating change in attention and awareness, often caused by medical issues (infection, dehydration, meds, electrolytes).

What to look for: Sudden onset, worse at certain times of day, inattention, recent UTI or pneumonia, recent med changes.

ICD-10: F05.

7Adjustment disorder

Emotional or behavioral symptoms within 3 months of an identifiable stressor (move to facility, loss of spouse, new diagnosis).

ICD-10: F43.20 (unspecified), F43.21 (depressed mood), F43.22 (anxiety), F43.23 (mixed).

8PTSD

Symptoms following exposure to actual or threatened death, serious injury, or sexual violence. Includes intrusion, avoidance, negative mood, and arousal symptoms.

In older adults: Veterans, Holocaust survivors, abuse history, recent trauma like a fall or hospitalization.

ICD-10: F43.10.

9Substance use disorders

Common in this population: Alcohol use disorder, opioid use disorder, sedative/hypnotic (benzo) use disorder.

ICD-10: F10.x (alcohol), F11.x (opioid), F13.x (sedative).

1What the MSE actually is

The MSE is the provider's clinical observation of the patient at this exact moment. Each category has a small set of common descriptors. Your job is to capture which ones the provider uses, in the provider's words.

1Why drug class matters

1The "tell now" list

If you see, hear, or read any of these, do not wait until the end of the visit. Tell the provider immediately.

2The "document carefully" list

1The 16 sections (in order)

1. Demographics & visit type — name, DOB, MRN, date, location, encounter type, provider name and credentials
2. Chief complaint (CC) — one sentence, ideally a quote
3. HPI — the story of what's going on, in paragraph form
4. Past psych history — diagnoses, hospitalizations, attempts, prior med trials
5. Past medical history — relevant medical conditions
6. Medications — current list with doses and frequency
7. Allergies
8. Social history — living situation, family, substance use, trauma
9. Family history — psych and substance history in family
10. Review of systems (ROS) — quick scan of physical and psych symptoms
11. Mental status exam (MSE) — see MSE module
12. Risk assessment — SI, HI, self-harm, substance use, fall risk
13. Assessment / impression — diagnoses with ICD-10 plus clinical reasoning
14. Plan — broken down by problem (med changes, labs, follow-up, referrals)
15. Time / billing details — total time and what it was used for
16. Signature

2Stable patient language

Most follow-ups are stable patients. There is still a real note to write. Stable does not mean nothing happened.

Sample stable HPI / interval phrasing

Sample stable plan

3How to revise a note

Drafting is half the job. Revising is what makes it billable, defensible, and clinically useful.

The revision checklist

1. Does the CC match the HPI?
2. Are SI, HI, and AVH explicitly addressed?
3. Does the MSE have all 11 categories?
4. Are diagnoses listed with ICD-10 codes?
5. Does the plan address each active diagnosis?
6. Is the med list current (doses, freq, any changes)?
7. Is time documented?
8. Does the complexity match the billing code?
9. Any em dashes? Replace with commas, periods, or line breaks.
10. Med name and dose spelling correct?

Weak vs strong examples

1New patient template (Office Ally layout)

Use for any first encounter, whether SNF or ALF. Each labeled section maps to the matching Office Ally field.

2Follow-up template (Office Ally layout, SOAP)

For monthly or bi-weekly follow-ups. Maps directly into the Office Ally fields.

1Full initial psychiatric evaluation (new patient, Office Ally layout)

Use this for any new patient, SNF or ALF. Output is the complete chart structured to drop into Office Ally fields. De-identified only.

2Full SOAP follow-up note (Office Ally layout)

Use this for any monthly or bi-weekly follow-up. Output is the full SOAP chart structured to drop into Office Ally fields. De-identified only.

3Stable patient SOAP follow-up (Office Ally layout)

Stable patients still need a complete chart. This prompt outputs the full SOAP note with stable-patient phrasing baked in, structured for Office Ally. De-identified only.

4SOAP follow-up with med change (Office Ally layout)

Use when the provider is starting, stopping, or changing a medication. Output is the complete chart with risk/benefit built in, structured for Office Ally. De-identified only.

5Refine and tighten a complete draft

Use this after running prompts 1 to 4 to polish the full chart before sending to Kat for signature. Catches PHI leaks, missing sections, and weak billing justification.

6Build the assessment notes paragraph

Use this when you need to develop just the Assessment Notes section to drop into the Office Ally Assessment & Plan field.

7Build the Care Plan / Plan Notes section

Use this when you need to develop just the Plan section to drop into the Office Ally Care Plan / Plan Notes field.

1The two main code families

• SNF (skilled nursing facility): 99304 to 99310. Called "nursing facility services."
• ALF (assisted living, custodial): 99324 to 99337. Called "domiciliary, rest home, or custodial care services" or "home/residence services" depending on year.

2Two ways to pick a code

1. Medical decision making (MDM): Based on complexity of problems, data reviewed, and risk.
2. Total time: All time on the patient that day (chart review, visit, documentation, coordination).

Since 2021, you can pick whichever level is higher. For psych in SNF and ALF, time-based billing is often easier to justify because chart review, MSE, and coordination add up.

3The three audit checkpoints

If an auditor reads this note, can they see why this code was billed? That is the test.

1. Time documented: Total minutes today (face-to-face plus chart review and documentation), with what activities filled that time.
2. Complexity shown: Number of diagnoses addressed, data reviewed, risk discussed.
3. Decision-making visible: The note shows the provider thought, considered options, and made a decision. Not just "continue meds."

4Code-by-code language

If billing 99307 (SNF, brief, stable)

If billing 99308 (SNF, low complexity)

If billing 99309 (SNF, moderate complexity)

If billing 99310 (SNF, high complexity)

1What the provider does in Rounds, for context

You do not work in Rounds, but knowing what happens there explains why Scribe behaves the way it does.

2Logging in and finding your patients

What you see depends on which providers you scribe for.

1. Open Scribe, pick facility and month.
2. Scan the patient list. Anyone with unfinished charting shows a "📋 N ready to chart" badge, where N is how many separate visits are waiting for that patient.

3The Ready to Chart section

Open a patient. At the top, a Ready to Chart section shows one card per pending visit, each labeled with its own date and visit type, for example "7/13 (UPDATE)".

This is what actually fixed the old "wrong date" and blended-note problems. Each visit was staged separately the moment the provider saved it in Rounds, so there is no reconstruction or guessing happening on your end.

4Charting one visit, start to finish

This is the full loop, and you will repeat it once per pending card.

1. Tap 🔄 Generate Note on the specific visit card you want to chart.
2. Pick a note template. Optionally add instructions to guide the draft. Tap Generate.
3. A review screen shows the generated note. Nothing is saved yet at this point.
4. Read it fully, then choose:
   • 💾 Save to Chart — commits the note permanently. That visit's card disappears from Ready to Chart.
   • 🗑️ Discard — throws away this attempt. The visit stays pending, and you can hit Generate again anytime.
5. If more visits are still pending for that patient, repeat this whole sequence for each one.
6. Once Ready to Chart shows "Nothing pending," everything for that patient this month has been charted.

5Marking a patient fully done

Once every pending visit card for a patient has been generated and saved, and Ready to Chart shows "Nothing pending," tap ✅ Mark Done.

6Key principles to keep in your head

7What every generated note must have: med justification

Before you Save to Chart, check that every psych med on the med list is actually justified somewhere in the note. This still applies exactly the same under Ready to Chart, it's a review-screen check now instead of a post-hoc one.

Then check the bottom of the note: treatment options section

Every note should end with a line similar to "Treatment options, risks and benefits, adverse effects reviewed" that names the actual med classes the patient is on. This section needs to mirror the med list exactly, not a generic boilerplate list.

• If the patient is on an antidepressant, antidepressants should be named in this section
• If the patient is on a benzodiazepine, benzodiazepines should be named in this section
• If the patient is on an antipsychotic, antipsychotics should be named in this section
• If a med class appears here but is not actually on the current med list, or a med class is on the list but missing from this section, that is a mismatch to fix before you save

8Using regenerate the right way

Regenerate now goes through the exact same review step as a first generate. It is your main tool for fixing med justification gaps and outright contradictions in the note. Give it a specific, direct instruction, the same way you would tell a colleague exactly what is wrong.

Fixing a missing med justification

If a patient is on an antipsychotic and the Psych ROS does not reflect it, do not hand-edit a sentence in. Discard, then regenerate with something like:

Fixing a contradiction between Rounds and the note

Sometimes the provider's raw Rounds comment tells one story and the generated note tells another. This is a hard stop, do not tap Save to Chart until it is fixed.

9Still worth checking, even with Ready to Chart

The new system eliminated cross-month bleed and wrong-date mixups by design, since each visit is isolated at the source. These are the checks that still matter every time.