Docs / Notes & Billing / How to review, complete, and sign medical notes

How to review, complete, and sign medical notes

Joint Academy supports both automated and manual note workflows.

In most cases, Joint Academy creates the note automatically and pre-fills much of the documentation for the clinician. The clinician then reviews the note, completes any missing information, and signs it. After signing, the note moves into the billing workflow for biller review.

Clinicians can also create notes manually when needed. In those cases, the clinician selects the note type and fills out the note directly.

What this workflow supports

  • automatically generated notes that are pre-filled by Joint Academy
  • clinician review before signature
  • completion of missing fields before finalizing the note
  • manual note creation when the note must be built from scratch
  • handoff of signed notes to the biller

How it works

The note workflow generally follows this sequence:

  1. Joint Academy generates a note in the background for a relevant event or workflow.
  2. The clinician opens the note and reviews the pre-filled content.
  3. The clinician adds or edits any missing or patient-specific information.
  4. The clinician signs or completes the note.
  5. The signed note is sent to the biller.
  6. The biller reviews it in the Billing queue and either approves it forward or discards it.
  7. If appropriate, the biller copies the finalized documentation into the EMR.

Where clinicians will see note work

Clinicians may encounter note tasks in several places:

  • Dashboard under items such as Medical notes to sign
  • Patient Profile in the Medical notes section
  • note creation actions such as New note from patient or messaging workflows

Example: automatically generated RTM note

Based on the current note example, an automatically generated note can include structured sections such as:

  • patient name and date of birth
  • Assessment
  • Goals
  • Plan
  • Purpose of visit
  • Device/software setup
  • Education and instruction
  • attached assets, such as Download as PDF

This means the clinician is not starting from a blank page in most RTM note workflows.

What to review before signing

Before signing a note, review:

  • the patient identity fields
  • diagnosis and treatment details
  • goals and plan
  • the purpose of the visit
  • device or software setup language
  • patient education and instruction details
  • any missing free-text areas or dropdown values

If anything is incomplete or inaccurate, update it before signing.

Step by step for clinicians

  1. Open the patient’s profile or task list.
  2. Find the note that needs review.
  3. Open the note.
  4. Read through the pre-filled sections carefully.
  5. Add any missing information that is still required.
  6. Correct anything that does not match the patient encounter.
  7. Review all structured sections before finalizing.
  8. When the note is complete, use the sign or complete action.
  9. Confirm the note no longer appears as pending clinician action.

Step by step for manually created notes

  1. Open the patient profile or relevant workflow.
  2. Select the option to create a New note.
  3. Choose the correct note type.
  4. Complete the required sections manually.
  5. Review the full note for accuracy and completeness.
  6. Sign or complete the note.
  7. Confirm it moves out of the clinician action queue.

What happens after signing

Once signed, the note is sent to the biller. The biller then reviews it in the Billing page, where the note can be previewed, accepted into the billing workflow, or discarded.

Tips

  • Do not assume every pre-filled field is final. Always review the note before signing.
  • Use the generated structure as a time-saver, but still treat the note as clinician-reviewed documentation.
  • Complete note tasks promptly so they do not delay billing.
  • When creating a note manually, choose the correct note type first so the workflow stays organized.

Common questions or notes

Does Joint Academy always create the note for me?
In most cases, Joint Academy creates and pre-fills the note automatically, but clinicians can also create notes manually.

Do I still need to review the note if it was generated automatically?
Yes. The clinician is still responsible for reviewing, completing, and signing the documentation.

What does the biller do after I sign?
The biller reviews the note, decides whether to move it forward or discard it, and then handles the EMR entry process.