ASGE Annual GI Advanced Practice Provider Course - Day One | July 2021-02

02_Creating a Quality GI Note-Enslin

Pdf Summary

The document discusses the key components of creating a high-quality gastrointestinal (GI) note. It highlights the importance of accurate and timely documentation, communication between providers, justifying medical necessity, meeting billing requirements, and supporting the level of service billed. <br /><br />The components of a high-quality note include the chief complaint, history of present illness (HPI), medications/allergies, past medical history, review of systems (ROS), physical exam findings, labs/imaging, assessment (including a differential diagnosis), and a plan. The document provides additional considerations such as patient consent and accommodations, antithrombotic management, and religion-based considerations. <br /><br />It emphasizes the need to capture key information in the HPI, such as onset, location, duration, character, aggravating factors, relieving factors, timing, and severity. It also discusses the importance of a comprehensive past medical history, including medications and allergies. <br /><br />The document suggests organizing the plan by problem if the patient has multiple complaints and advises documenting the time spent in the EHR. It addresses note burnout and offers strategies to increase efficiency, such as learning the EMR functions, reviewing and editing auto-fill portions, and reducing documentation volume while emphasizing quality and accuracy. It also emphasizes the importance of effective and timely documentation for good patient care, communication with referring providers, risk management, and reimbursement. <br /><br />Overall, the document provides guidance on creating a quality GI note that accurately reflects the patient's care and supports effective communication and billing requirements.

Keywords

gastrointestinal note

high-quality note

accurate documentation

communication between providers

medical necessity

billing requirements

chief complaint

history of present illness

past medical history

assessment