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Compliant chart note practices

Key guidelines for completing, signing, and managing chart notes compliantly on Fay.

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Is charting time included in the appointment time?

Charting time is not included in the appointment time. Insurance reimburses for one-on-one patient care, so charting must be completed outside of your appointment time. Fay’s charting tools and templates are designed to help make documentation more efficient so notes can be completed as smoothly as possible outside of session time.

Do I need a chart note for canceled or no-show appointments?

A chart note is not required for canceled or no-show appointments. When an appointment is canceled or your patient is a no-show, simply update the appointment status to Cancelled or No-show/last-minute cancellation.

When do chart notes need to be completed?

Chart notes must be completed and signed within 24 hours of the appointment end time. Incomplete or unsigned notes are not sufficient for reimbursement. To support accurate and compliant insurance claim submission, the following steps must be completed within 24 hours of the appointment end time:

  • Record the correct appointment length and site of service

  • Complete and sign your chart note

Note: Completing and signing chart notes within 24 hours is consistent with payer and regulatory expectations around timely documentation of clinical services.

Can I pre-fill my chart notes?

Chart notes cannot be pre-filled due to insurance billing requirements. Once you complete a chart note for a patient, that information will automatically carry over to their future notes, making the charting process faster over time.

Who can see my chart notes?

Once a note is signed, information in your freeform notes and the insurance-required section is added to your patient’s medical record and may be viewed by insurance companies or members of your patient's care team.

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