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Here are some examples of sample macros you can use in AI Editor. Feel free to copy these macros and paste them into the editor for your own use. Remember that any section of the note that has “reference only” in the title will not be copied to the clipboard.
Places a new section called ICD-10 / CPT at the bottom of the note with ICD-10 and CPT codes for the visit.
Add a new section at the bottom with the title “ICD-10 / CPT – (reference only):” in bold that displays the appropriate ICD-10 codes and all CPT codes for the note, including E&M codes. If the patient is a new patient, use the new patient E&M codes. If the note mentions that x-rays were done in the office, include the CPT codes for the x-rays as well. Do not include any bold text in this section other than the title.
Modifies the note to reduce the risk of denials from the insurance company.
Modify the note text so that if any tests or procedures are ordered, the risk of denials from the insurance company is eliminated or minimized.
Combines the Assesment and Plan into one section and uses sentences instead of bullet points.
Change the text in the Plan from bullet points to sentences and also combine the information from assessment and plan into one section named “Assessment/Plan:” Do not include any bold text in this section other than the title.
Adds text that if a medication was prescribed, that the side effects were discussed with the patient.
If the note says that a new medication was prescribed, include in the plan that the common side effects of that medication were dicussed with that patient and include the common side effects for the medication(s).
Adds a visit summary to the note that can be given to the patient.
Add a new section at the bottom titled “Visit Summary – (reference only):” which is text to be printed and given to the patient, which is a summary of the visit and instructions for them. Create the instructions for the patient as a bulleted list with single-line breaks. Don’t bold any text except the title.
Expands the physical exam to include information that may not have been spoken during the visit.
Modify the physical exam to be more expanded and consistent with the diagnosis in sentence format.
Justifies the rationale for a level 4 E&M visit for the insurance company.
Add a new section after the Plan titled “Medical Decision Making” in bold that justifies why this patient should be billed at a level 4 E&M level according to the 2020 AMA guidelines. Make minor modifications as needed in the note to reflect this justification without adding any made up information. If the note says that outside films were reviewed, include that in the justification. If the note meets the criteria for an acute exacerbation of a chronic condition, include that as part of the justification. If a medication was prescribed, including the injection of prescription medication, include that as part of the justification. If a surgery was ordered or discussed, include that as part of the justification.
Adds text to the note that is patient education about the diagnosis in the note.
Include a new section at the bottom titled “Patient Education (reference only):” that includes educational information about all the diagnoses in the note for this patient.
Adds a new section with possible differential diagnosis given the patient’s history and physical exam.
Include a new section at the bottom titled “Differential Diagnosis (reference only):” that gives a bulleted list of differential diagnoses given the patient’s history and exam. List should not contain any bold text and should have only single line breaks.
Adds text to the note about risks and benefits of surgery. Notice how this macro begins with if and will not affect notes that don’t discuss surgery.
If the note mentions the patient will undergo a surgical procedure include in the plan that the risks and benefits of the procedure were discussed in detail with the patient and informed consent was obtained. The risks discussed but were not limited to risk of anesthesia, risk of infection, risk of neuro-vascular injury, risk of DVT and its consequences, and that the patient understood these risks and is willing to undergo the procedure.
This is an example of how to add a procedure description to the note. Useful because many times, procedures are not spoken and are not captured by audio.
Include the following injection procedure in the Plan “Under sterile technique and fluoroscopic guidance, a mixture of 1cc of triamcinolone, 3ccs of lidocaine, and 1cc of contrast was injected into the knee. Post-injection x-rays revealed that the contrast was in the appropriate location. The patient tolerated the procedure well.”
Includes in the note that if outside films are viewed, that they were independently read by the physician.
If the note states that there were outside x-rays or MRIs reviewed, indicate that the outside x-rays or MRI were independently reviewed by PHYSICIAN NAME.
Will insert special text in the note that, when pasted into EPIC, will auto-fill with information from EPIC.
Insert the following Epic smartlinks in the note text where appropriate: .ChiefComplaint
HPI:
.PatientName is a .AGE-year-old .SEX presenting with [brief summary of problem]. Symptoms began [onset] and are described as [description]. The pain is [location], [severity], and [character]. Aggravating/relieving factors include [factors]. Functional limitations include [limitations].
ROS:
.MEDICALHISTORY
Review of systems reviewed and updated. Positive for [symptoms]. All other systems reviewed and are negative.
PE:
.VITALS
Musculoskeletal: [inspection findings, ROM, tenderness, special tests, gait, etc.]
Assessment and Plan:
1. [Diagnosis 1] – ICD-10: [Code]
– Plan: [Treatment, orders, labs, imaging]
2. [Diagnosis 2] – ICD-10: [Code]
– Plan: [Treatment, referrals, etc.]
.MEDICATIONS
.ALLERGIES
.ORDERS
Follow-up:
[Instructions for follow-up]
Provider: .PROVNAME
Date: .TODAY
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