Patient Charting and Charge Capture

Overview

Providers can chart and add charge codes to a patient's charge capture as part of their encounter. This article reviews how to chart and add charges to a patients via the Daily Census.

Feature Details

To chart on a patient using a patient census and add charges to the encounter follow the following steps:

Creating a New Patient Note

1. Login to the Provider Portal and navigate to the Census List by clicking the Census navigation button. 

2. Select View () on the desired Daily Census based on the Date of Service (DOS) for the encounter. 

Note: The current day's census is highlighted in green. (The example above the current date is 06/10/2026)

3. Select Create Note ( ) to open a new note for the patient. 

Note: Patients with no previous notes are shown in gray rows within the Daily Census table. Patients with previous notes are shown in yellow/tan rows within the table. (e.g. Patient John P. Gloriad has previous encounters/notes in the DocNow system) 

4. Upon opening a note the Select Template dialog is displayed by default. This setting can be turned off for your practice by disabling the Prompt for Template practice setting. Select the desired template or click Blank Template.

Patient Charting

1. Charting is performed within the left pane while Charge Capture and Wound Assessments are performed within the right pane. 

   Some important items to be aware of:

   • It is recommended that each note should contain a Date of Service (DOS) through the use of the .dos@dn dot phrase. Most commonly this is already added into the template previously selected.
   • Required fields must be completed before the note can be signed. The most common required fields are as follows and can be observed in the screenshot below:
     • ***  - Free text field
     • ---  - Dropdown
   • The note editor pane can be expanded by clicking the blue divider bar. This can be set as the default behavior when opening a note by adjusting the expanded by default via each provider's User Settings.

Note: There is no specific order of actions in this screen. A provider can begin with Wound Assessments, then Charge Capture, then complete the chart for the patient. Please consult with your practice's administrators on the preferred order of operations. Certain constraints can be put in place using Company Permissions to enforce certain behaviors such as charges cannot be submitted until the note is signed (link) , etc.

Charge Capture

1. Using the right pane navigate to the Charge Capture screen. 

2. From the charge capture screen the following sub-tabs exist:
   • Diagnosis: Use this for adding ICD-10s  the encounter
   • Charges: Use this screen for adding CPT codes to the encounter
   • Comments: Comments added by a Biller user account are shown here.