Approval and attestation

A worksheet is a draft until a clinician approves it against the signed record.

Who can approve

• Clinicians and assistants can create and edit worksheet drafts.
• Only a clinician can approve.

Approve a worksheet

1. Sign the note. Approval needs a verified signed record.
2. Open Visit workflow → Coding worksheet and check each line: the code, its description and its supporting excerpt.
3. Make sure every code is valid for submission. Category headers cannot be approved.
4. Tick the attestation. By approving, you confirm the date of service, that the documentation supports each code, the code's specificity, and that applicable guidance was followed.
5. Choose Approve.

Approval checks that the note, its supporting documents and the code release are the same ones the worksheet was built on.

When approval becomes stale

An approved worksheet is tied to exactly what was reviewed. It becomes stale, and needs a new draft and approval, when:

• an amendment is added to the note,
• a supporting document changes,
• the code release used for the date of service is replaced.

Saved codes do not move to a new release automatically. Earlier decisions stay in the worksheet's history, attributed to the person who made them and to the record they actually reviewed.

History

Every save and approval keeps the actor, time, reason, the saved source text and its hash, and the code release. Use it to answer "who coded this, from what, and when".

What Terra does not do

Terra does not submit claims, determine coverage or medical necessity, or sequence codes for billing. Approved worksheets are not inserted into the signed note or the export package.