PCDT and consent terms in the EHR: the diagnosis code does the work

Today, a diagnosis is a code typed into a box

What it requires comes later, when someone remembers it or a denial (glosa) arrives: the PCDT criteria, the exams, the signed TER for a high-cost medicine. The information is scattered across PDFs, paper and folders, and management only finds the gap at audit.

In Aente, the CID is where the workflow starts

The protocol appears where the doctor is working, what is required cannot be left blank, the term is printed or sent from the same screen, and billing sees what is still missing before the visit closes.

For those who need to trust what the record holds

Medical directors

The protocol is followed at the moment of the decision, and the visit only closes with the required items filled in. Less time chasing doctors after the visit.

Hospital owners and managers

Complete documentation for authorizations and audits, with the signed term stored in the visit itself, not in a drawer. Less rework in production.

Insurers, audit and quality

Diagnoses coded in the official CID-10, protocol answers in a structured form instead of free text, and the protocol version used kept with every visit.

Billing

Each protocol appears in the SUS billing review with its portaria, the documents it asks for and whether the TER is signed. The warnings reduce the risk of denials and rework.

For public health managers and providers who bill SUS

The same chart serves the health department that oversees the network and the contracted provider that needs to be paid for its production.

Municipal and state health departments

Every unit in the network follows the same Ministry protocol, in the same version, and each visit keeps the version it used. Management gets complete records in the same standard across the network, ready for audit.

Contracted clinics and philanthropic hospitals

Diagnoses are recorded with the CID-10 of the current SIGTAP list, and the production file uses the code SUS expects, including for the COVID-19 markers (U07.1 and U07.2). It reduces the risk of production rejected because of a code.

Specialized Component medicines (CEAF)

What the protocol asks for a high-cost medicine, such as criteria, exams and the signed TER, is gathered during the visit itself, not assembled later from PDFs and paper.

Review before submission

In the SUS billing review, each protocol shows its portaria, the pharmaceutical assistance component, the documents and exam validity it asks for and whether the TER is signed. The team fixes it before submission, not after the denial.

How it works: one visit, step by step

From diagnosis to billing, everything happens in the same chart.

1

The doctor records the diagnosis

The CID tab of the chart searches the official DATASUS CID-10, with the current SIGTAP list, by code or by everyday words. The doctor's most-used codes come first, and the full index can be browsed. Each diagnosis is principal, secondary or associated cause.
2

The protocol appears under the diagnosis

If the CID is covered by a PCDT, a protocol panel opens right under the diagnosis table. A subcategory finds the protocol of its category. If a CID belongs to several protocols, the doctor picks the one that applies, and "Não se aplica" (not applicable) dismisses one.
3

The doctor fills in a structured form

Tabs follow the protocol: diagnosis criteria, treatment and monitoring, with a protocol summary first. Questions show units and criteria, and appear only when they apply. Age, sex and weight come from the patient's record and vital signs.
4

Required items are enforced

"Finalizar Atendimento" (finish visit) lists every required item still blank, on the chart, on the open protocol and on added procedures, and takes the doctor to it. Yes/no questions ask for Yes or No, so "no" counts as an answer.
5

The TER comes ready

If the protocol has a TER, it appears in the same panel with the patient, the doctor and their council registration filled in. The doctor ticks the medicines of the treatment and prints the term for signing during the visit, or sends it to the patient portal.
6

Everything stays in the visit

Protocol answers print in the chart report (PDF). The signed term is stored in the visit and can be downloaded by the team and, when signed in the portal, by the patient.
7

Billing sees it before it is too late

In the SUS billing review, each protocol shows its portaria, the pharmaceutical assistance component, the documents and exam validity it asks for, the answers given and whether the TER is signed. Warnings flag a protocol not opened, an empty form, missing required items or an unsigned TER.

What Aente does

The official CID-10 at the center of the chart, not a text box

DATASUS CID-10 with the current SIGTAP list, and principal, secondary and associated diagnoses per visit. Each unit follows its country: CID-10 in Brazil, ICD-10-CM in the United States and CIE-10 in Mexico. The diagnosis is coded the way SUS expects and opens the right protocol.

Record the diagnosis, get the national protocol form

Summary, criteria, units and conditional questions on the same screen as the diagnosis. Protocols are the same for every clinic, structured from the published PCDTs, updated centrally when the Ministry publishes a new version and released after review. A finished visit keeps the version it used.

Required items can't be skipped

Clinics mark items as "Obrigatório" (required) in their own forms. "Finalizar Atendimento" shows what is missing, by form and tab, and opens the right step. Items that don't apply to the patient never block. Complete documentation without chasing the doctor afterwards.

The protocol's TER, pre-filled

The protocol's official term, reproduced word for word from the Ministry's PDF. Aente fills in the patient's name and CNS, the doctor's name and registration (for example, CRM-SP) and the unit, and marks the chosen medicines. Print it, collect the signature and attach the photo or PDF without leaving the visit.

Patients read and sign the TER in their portal

The doctor signs on screen and sends the term. The patient gets an e-mail, reads the full term in the portal, answers the data-use authorization and signs on screen, as legal guardian if needed. They can sign after the visit: the term stays available until it is signed.

Billing sees the protocol before the denial does

In the SUS billing review, each protocol shows what was answered and what is missing, including the TER. Answers also print in the chart report, ready for authorizations and audits. It reduces the risk of denials and rework.

What every visit records

Structured data, stored in the visit, ready for internal audit, authorizations and billing.

Diagnoses in the official CID-10, each as principal, secondary or associated cause.
The protocol applied and the protocol version used in the visit, or the "Não se aplica" mark.
The answers to the protocol form, with units and criteria, printed in the chart report (PDF).
The required items filled in: the visit only closes complete.
The TER with the ticked medicines and the signed term, printed and attached or signed in the portal.
The status of each protocol in the SUS billing review, with warnings for what is still missing.

The TER text is the Ministry's. Aente only fills it in.

The term is reproduced word for word from the PCDT published by the Ministry of Health. Aente fills in names and choices and never rewrites the term. When a protocol requires a term but publishes no model, Aente says so, and the doctor attaches the clinic's own signed document.

Two ways to collect the signature

Print and attach

Works everywhere. The term comes ready to print, with the Ministry's signature fields. The team collects the signature during the visit and attaches a photo or PDF of the signed paper, stored in the visit with a hash and digital signature of the file.

Sign in the patient portal

The convenient option for follow-ups and telemedicine. Electronic signature in the patient portal, with date, time, a unique code and an integrity check of the document. The signed PDF carries both signatures and is stored with a hash, a digital signature of the file and the IP address. Any change to the file can be detected, and a signed term can't be edited or signed again.

Coming soon: Generating LME and APAC from the protocol is on the roadmap.

Frequently asked questions

Does Aente change the TER text?

No. The text is the one in the PCDT published by the Ministry of Health; Aente only fills in names and choices.

Does the patient have to sign in the portal?

No. The team can print the term, collect the signature during the visit and attach the photo or PDF.

What if the protocol has no TER model?

Aente says so, and the doctor attaches the clinic's signed document.

The protocol doesn't apply to my patient.

The doctor marks "Não se aplica" and the protocol is no longer required in that visit.

Where do the protocols come from?

They are structured from the PCDTs published by the Ministry of Health and released to doctors after review. When a new version comes out, the protocol is updated for every clinic, and a finished visit keeps the version it used.

Does Aente prevent denials?

No system guarantees authorization. Aente shows billing what is missing in each protocol before submission, which reduces the risk of denials and rework.

Does a blank required item block the visit?

Yes: "Finalizar Atendimento" only completes with the required items filled in. A pending TER or billing item only shows a warning, without blocking.

The right protocol at the moment of diagnosis.

Talk to a specialist to see the PCDT and the TER in the chart of your hospital or network. Clinics can create their organization account and start today.

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A chart that knows the protocol.