Documentation Of An E&M Office Note – 5 Things Needed For A Good Note!

The implementation of Electronic Health Records saw the creation of a model of documentation that included significant portions of records being cloned or copied, cut and pasted.  Large voluminous templates for the history and examination portion of these notes were developed.  The insertion of these pre-determined text sections of the note, lead to large notes with large amounts of superfluous or duplicative information, day after day or visit after visit, that, honestly, were unnecessary and not helpful in the care of the patient, according to many physicians.  Finding the "guts" of the note, the part that tells what the physician thought and did, were things that became very time consuming and tedious to locate.  The recent changes involved in the discussion of this webinar have given providers a different focus in their notes.  Away from counting bullet points.  Understanding the new guidelines has been difficult for some but the tools offered in this presentation should help change that.

The rules for documentation of office and other outpatient Evaluation and Management services have changed significantly in the past few years.  In 2021, the AMA significantly restructured documentation rules for these services.   In 2023, the documentation rules for the remainder of the evaluation and management service codes were also changed to the rules created in 2021.  These changes we are told were made to allow physician’s documentation of their services to be more intuitive.   Gone is the requirement for counting of the bullet points of a history and examination.  Documentation in 2021 was all about the items on the Table of Elements of Medical Decision Making.  The documentation was now about the number and complexity of problems addressed at the encounter, the amount and complexity of data to be reviewed and analyzed and about the risk of complications and/or mortality and morbidity of the patient management.  The focus of required documentation changed significantly.  

This webinar is intended to define 5 things needed for a good note.  Things that will help with a provider creating a compliant note. 

Webinar Objectives

Documentation of office visits has become one of inserting text and oftentimes the rationale and reasoning for the physician’s actions are left out or lost in the process.

Making notes simple, to the point and compliant is the goal of every provider.  That is the goal of this webinar.

Webinar Agenda

• Each of the three areas of the Table of the elements of medical decision making will be reviewed. 
• Compliant documentation of each of the three columns of the table will be discussed.
• The top five of items needed for a good note will be identified

Webinar Highlights

• Documentation tips for compliant documentation of the number and complexity of problems addressed at the encounter
• Documentation tips for compliant documentation, the amount and complexity of data to be reviewed and analyzed
• Documentation tips for compliant documentation the risk of complications and/or mortality and morbidity of the patient management
• Key documentation phrases for visits that are incident to or split shared
• Identifying five things needed for good, efficient, compliant documentation of an office visit

Who Should Attend

Billers, Auditors, Office and Practice Managers, Physicians