Documentation
Oncology documentation and ICD-10 codes that start from the provider's plan
In oncology, the provider's plan is the source of truth. The note records it, the ICD-10 codes describe it, and the care team works from it. OncoNexus drafts the note and suggests ICD-10 codes from the visit conversation. Your provider reviews and approves them, so the record and the follow-up start from the same plan.
One plan, three uses
- The note records what the provider decided
- The ICD-10 codes describe the diagnosis in the record and for billing
- The task list tells the team what happens next
When all three come from the same plan, nobody on the team is working from a different version of what the provider decided.
What oncology documentation needs to say
ICD-10 guidance stresses that complete documentation in the record is what makes accurate coding possible.1 For cancer, the details that matter are ones your provider already says out loud in the visit:
- The anatomic site and which side, rather than a general word like "mass"
- Whether the cancer is primary or secondary, and where it has spread
- The stage, when known
- Whether the cancer is active or in the past, and whether treatment is for active disease or to prevent recurrence
- Hormone receptor status for breast cancer, which has its own codes
- Related conditions the provider is managing, such as anemia from chemotherapy
Codes should reflect the highest level of detail in the record, and only conditions the physician is managing or treating are coded.2
What your provider reviews
- A draft visit note
- Suggested ICD-10 codes, drawn from what was said in the visit, with a flag on any code that needs a second look and any problem that has no code yet
- An action plan, with a suggested owner and due date for each task
Your provider can change any of it. Nothing moves until they approve. After that, each task goes to its owner, and the patient gets a plan in plain language.
To put the note in your EHR, copy it from OncoNexus and paste it in. You can copy the whole note or just the problems, codes and plan, as plain text or with headings and bullets.
The aim is follow-through, not a faster note
OncoNexus does not set out to replace how your clinic documents care. The draft note and codes are there because the plan has to be written down before a team can act on it.
What OncoNexus adds is the step after: turning the approved plan into tasks with owners and due dates.
What stays the same
- Your EHR stays in place. OncoNexus works alongside it.
- The visit is recorded only with the patient's permission.
- Your provider stays in charge of each plan.
- OncoNexus is HIPAA compliant, and we sign a Business Associate Agreement with every clinic.
Questions clinics ask
Is OncoNexus a scribing service?
No. What the provider decides in the visit tells the team what needs to happen next, and OncoNexus turns that into tasks with owners and due dates. The note and ICD-10 codes we draft for your provider to approve are the record that plan comes from.
Does the provider have to approve the note and codes?
Yes. Everything OncoNexus drafts stays a draft until your provider reviews and approves it.
What ICD-10 codes does OncoNexus suggest?
Codes drawn from what was said in the visit, as suggestions for your provider to review, accept or change.
How does the note get into our EHR?
After your provider approves, you copy it from OncoNexus and paste it into your EHR. You can copy the whole note or a part of it, such as the problems, codes and plan, as plain text or with headings and bullets. OncoNexus works alongside your EHR.
Are patients recorded without their permission?
No. A visit is recorded only with the patient's permission.
Is patient information protected?
Yes. OncoNexus is HIPAA compliant, and we sign a Business Associate Agreement with every clinic.
More on how we work with clinics
A 3-month pilot for community oncology practices.
1 to 5 providers, whatever your clinic's size. No charge, with hands-on support. Clinics in the pilot get a discounted price after it ends.