Sessions & charting

Starting a session

Every session is tied to a real appointment — this keeps a visit's date, time, service, and provider in exactly one place instead of two records that could disagree. There are two ways to start one:

• From an already-booked appointment — use the Start session link on the Calendar. The appointment's service, provider, location, and time carry straight into the chart, read-only.
• Walk-in or retroactive charting — choose New session from a patient's page. Pick the service, provider, location, and date/time (defaulting to now), and a matching appointment is booked for you automatically as part of saving the session — no separate booking step.

Either way, the form itself is laid out as four tabs, with a summary panel alongside it that stays visible as you move between them — clicking a summary section jumps you straight to the tab that edits it:

• Notes — any org-defined custom session fields plus a freeform note for the visit, written with a formatting toolbar rather than a plain text box — bold/italic, links, lists, checklists and headings
• Pulse & Tongue — pulse position and quality, and tongue body color, coating and shape — pick as many of each as apply (for example a pale, purple body with a swollen, cracked shape)
• Pattern & Technique — the TCM pattern identified and the technique applied
• Points — the acupuncture points used, with laterality (left / right / bilateral)

The point picker filters a large point list by name so you don't have to scroll a long checklist — a meridian expands automatically once it has a selection or a matching filter.

There's no built-in pain/symptom score — practitioners track outcomes differently enough (0–10? a named scale? per-complaint?) that it's a fit for custom session fields instead of a one-size-fits-all built-in. Any custom fields your organization has defined (in Settings) show up at the top of the Notes tab, under a Fields heading with a Customize fields button that takes you straight to the chart editor in Settings.

Starting from a protocol or a past session

A protocols strip on the session form lets you apply a saved protocol with one click, pre-filling points, pulse/tongue, and pattern/technique so you're editing instead of starting from a blank chart. See Protocols.

When the patient has an earlier session, a Copy from last session button does the same thing from their own history instead of a saved protocol — it carries points, pulse/tongue, pattern/technique, and any diagnosis codes forward (not the note or custom fields, which describe that visit, not this one). Next to it, Clear session resets every field back to a blank draft in one click. Both are safe to click even after other charting — nothing is lost, since History and Undo can always bring back what was there before.

Editing and deleting a session

Opening a charted session from the calendar, the dashboard, or an invoice lands on its details page: a read-only view of the whole chart, with Edit, Superbill, Download PDF, and Delete beside the status. A draft skips straight to the editor so you can keep charting, and the patient's session list offers both View details and Edit. Save changes in the editor returns you to the details page. Deleting a session sends it to the trash rather than removing it permanently — see Trash & recovery.

Download PDF produces a record of the chart — practice letterhead, visit details, every charted field, and the signature line if signed — to save, print, or send to another provider. It's separate from the superbill, which is the billing document.

History and undo

Every save is kept, not just the latest one. Click History in the editor to open a right-hand drawer listing every save, status change, restore, and sign/unsign event for the session, newest first, with who made each change and — where there's something to compare against — a quick summary of what changed (points added/removed, pattern changed, notes changed, and so on). A changed note or other long field is click-to-expand, revealing the actual before/after wording rather than just "changed." A run of consecutive plain saves collapses into one expandable group so a long editing session doesn't turn into a wall of near-identical rows.

Any past version can be brought back with Restore this version. Restoring never rewrites history — it loads that old snapshot and writes it forward as a brand-new entry at the top of the list, so the log itself is proof nothing was silently erased.

The Undo button next to History is a separate, narrower shortcut: it cancels the note field's pending autosave (notes save on a short debounce, so there's a brief window where a keystroke hasn't been persisted yet) rather than reverting something already saved. Once that window has passed, clicking Undo again steps back through your own most recent saves one at a time, the same as clicking Restore in the History drawer — it's only ever offered for saves you're still actively walking back from, not as a general-purpose replacement for the drawer. Redo, next to Undo, steps forward again through whatever Undo just stepped back from — it's only available right after an Undo, and clears once you make a new edit.

Signing and locking

Toggling a session to Sign session marks it as the attested record of the visit and locks it completely. On a signed session every field in the editor is disabled, Save changes is disabled, autosave is off, and status changes and Restore this version are blocked — the server rejects any change, not just the screen. Opening a signed session's editor directly shows a notice at the top explaining it's read-only.

To make a correction, click Unsign to edit on the details page (or Unsign in the editor). Unsigning is its own logged action in the History drawer, and the session becomes an ordinary editable chart again until it's signed a second time. Signing never discards the pre-signature save history — every earlier save is still in the drawer, and restorable once the session is unsigned.

Draft and complete

Every session starts as a Draft — including one you fill out in a single sitting — until you flip the toggle at the top of the editor to Complete. A patient's session list and the Calendar both show a draft badge, so an unfinished note never quietly looks the same as a finished one.

Once a session exists for an appointment, the same Calendar row shows Draft note or Charted instead of Start session — click it to jump straight back into that session.

Superbill export

Wherever a session exists on an appointment row, a small receipt icon opens a page to generate a patient-facing superbill — a document a patient can submit to their own insurer for out-of-network reimbursement. It suggests CPT codes and units from the visit's treatment minutes and technique, and lets you pick the diagnosis code(s) that apply before generating a PDF.

Treatment minutes default to the appointment's scheduled length, or to the service's own treatment-time default if one is set (Settings > Scheduling, on the service) — useful when a slot routinely includes intake or rest time that isn't hands-on contact. Either way you can edit the number for a single visit. What you leave there is saved with the visit. Under the default settings the minutes only decide whether a code is suggested at all (a visit under 8 minutes gets none); with time-based additional units switched on (see below), the suggested units update as you type.

The diagnosis list is filterable, and the codes you pick are remembered two ways: Copy from last session carries them onto a new chart, and Save as this patient's default makes them the suggestion on every future visit for that patient. A visit that reaches the superbill page with no diagnosis yet offers those saved defaults — or, failing that, whatever was used at the patient's last coded visit — as a one-click suggestion rather than filling them in silently.

By default a superbill bills only the initial acupuncture unit (97810 or 97813), however long the visit ran. Additional 15-minute units (97811/97814) are defined as “with re-insertion of needle(s)” — in practice a new needle set — and Charts can't record one yet. A practice that does track that itself can switch on time-based units under Settings > Billing.

Also performed this visit covers what the treatment minutes can't tell us. The acupuncture codes are worked out from recorded time and whether electro-stim was used, but nothing in the chart says for certain that you also ran infrared or did manual therapy — so those are a checkbox, and they only appear on the superbill when you tick them. Manual therapy (97140) carries a note because insurers bundle it with acupuncture performed the same day unless their own rules say otherwise. Cupping and moxibustion aren't listed: neither has a CPT code of its own, so bill those as an ordinary cash-pay line on the invoice instead. Anything you tick joins the table at the bottom of that section, which is exactly what will print.

If your practice has turned on more codes under Settings > Billing, they appear here too, grouped as consultation (E/M) visits, preventive visits, herbs and other procedures. A consultation is only suggested: 99203 on a patient's first chart, 99213 after that, each with an Add button, and never ticked for you. When you add one on a day you also needle, it prints with modifier 25 (for example 99213-25), because without it insurers treat the consultation as part of the acupuncture. Some payers don't cover a same-day consultation at all, so check yours. Preventive visits and herbs print marked as patient responsibility. A service can also start a superbill with codes already ticked, or with no acupuncture codes at all (Settings > Scheduling); change any of them on the visit and that becomes this visit's own choice.

Charges come from the invoice issued for that visit — the priced lines, the total, what was paid and how. You never retype a price here: the invoice already owns it, so the two documents cannot disagree. Only treatment charges appear: herbs, retail products and package purchases are left off, even when they were rung up on the same invoice, because a total higher than the procedures listed above it is one of the more common reasons a submission gets sent back. The document says how many lines were left off so the difference from your patient's receipt is never a mystery.

If the invoice covers several visits, only that visit's own lines are shown. Amount paid is stated whenever it can be stated exactly — either the printed lines are the whole invoice, or the whole invoice is settled, in which case those lines certainly are too. It is left off only when a part-paid invoice covers more than the lines shown, since splitting that payment across them would put a figure on a reimbursement document that nothing reconciles against. The superbill says which of those applies.

The PDF separates who is being billed under — your practice name, address, phone and Tax ID — from the place of service, meaning the location the visit actually happened at and its CMS place-of-service code. With one location those are the same thing and the address isn't repeated. A practice with a second location can give it its own billing details under Settings > Scheduling, and superbills for visits there use them automatically.

A signature block is off by default and can be switched on under Settings > Billing — either a blank ruled line you sign by hand, or each provider's uploaded signature filled in automatically. Some plan administrators ask for a signature; if yours does, turn it on. A signature is per-provider and never shared, so one practitioner's is never applied to another's superbill.

Every export is saved. Generating a PDF also records what it said — the procedures and units, the diagnosis codes, the provider and practice details, any charges, and the treatment minutes it was based on — and who generated it. They are listed under Previous exports at the bottom of the superbill page, newest first, each with a Download again button that gives back the same content even if a code, a setting or the chart has changed since. The page also says when what is selected now would print differently from your most recent export. Only the content is kept, not the file: the practice logo and provider signature come from what is set up today. A corrected superbill is a new entry, and earlier ones are never edited or removed.