Introduction
Visit notes serve three primary functions:
They give context to Loula on what happened during a visit. We audit these visit notes regularly. If we notice that the visit note describes non-covered service occurring during a visit, we may hold your payment for that visit.
They are shared with health plans in case of an audit.
They serve as a record-keeping for you.
Note: Visit notes are not shared with clients.
What should go in a visit note?
Visit notes should be a brief summary of what happened during a visit. They should have two components:
A short summary of how the client is doing
A short summary of the services you provided the client
Below are a few examples of visit notes that you might write:
For a prenatal visit:
Client is at risk for gestational diabetes, but otherwise pregnancy going well. Discussed birth plan, meal planning, partner support (partner is Henry). To follow-up with handouts.
For a labor & delivery visit:
Arrived to Kaiser at 4pm — client in active labor, contractions every 3-5 min. Led client through breathing exercises, demonstrated for partner (Nisha) how to provide physical support for client. Delivery at 7pm with no medical intervention. Lactation support immediately after delivery.
For a postpartum visit:
Client feeling overwhelmed after partner is back to work. Physically okay. Discussed baby sleep schedule, helped with baby bath.
For a miscarriage/abortion visit:
Discussed physical recovery after miscarriage with client. Provided emotional comfort and guidance on grief/loss.
Best practices
We encourage you to keep additional notes on your visits outside of the short visit note you write. For example, you may work on a birth plan worksheet with a client. You should keep the details of the actual birth plan in a separate document. For the visit note when submitting a visit on Loula, it is sufficient to summarize and write "Worked with client to develop birth plan and preferences."
They should not include non-covered services. You may choose to provide non-covered services outside of visit want to bill insurance for. Your documentation for those services should be completely separate from the covered visits. Learn more about non-covered services
You should not provide medical services during visits. Likewise, your visit notes should not reflect that medical services are being provided. Refrain from using medical terminology, such as "diagnose," "administer," "prescribe" to describe the services you are providing.