I will now take that just a step further and we'll talk about creating a quality GI note. How do we put what Dr. Call just told us onto paper? And so I'm going to review the key components of a high-quality note, outline the key information that everybody should make sure that we're including in each note that we write for both inpatient and outpatient. We'll also discuss the new billing requirements, and I'll try to give some tips and strategies to increase the efficiency and reduce that note burnout. To start, I think it's important to acknowledge the importance of a quality note. A note should be accurate and timely. It's a record of the patient's care, and importantly, it's a communication. It's going to serve as your communication as the GI provider to the referring provider, to the primary care provider, and to any ancillary services. It also justifies the medical necessity of the services that were rendered. Should demonstrate that the standard of care was met. This is really important for risk management, and then it will support the build level of service. These are the key components of a high-quality note, which I'll go through. But one thing that I want you to think about as we go through, specific to GI, can the patient consent? And that would be an important thing to put into our notes, so that the endoscopist, when they are preparing for the procedure, seeing the patient, they know who's going to consent for them if they can't themselves. How do they best contact them? Does the patient need any accommodations? I think in a hospital setting, to make sure that that's communicated ahead of time if they need a higher lift, so that your endoscopy nursing staff can be prepared for that. Antithrombotic management, and I should add diabetic management is another important one. So if you're recommending a procedure, put any changes that you're recommending or requests for changes right into the note. And then other things, such as any underlying patient concerns or specific religious preferences. If they're going to refuse blood products, and you're talking about a high-risk endoscopic procedure, that should be noted in your note as well. So the first part of a note is the chief complaint, and this is the reason for consultation in the patient's own words. So for example, I'm passing blood mixed with stool for three days. The next is your history of present illness. And with this, you want to specify your introduction and your purpose. Why is the patient there? Old cards can be really helpful in your HPI. It's the onset, location, duration, character, aggravating factors, relieving factors, timing, and severity. I like to include a mini-review of systems in the HPI, those pertinent positives and pertinent negatives, and then your interval history if it's a follow-up visit, what's happened since the last time you saw them. And so for example, this is a 72-year-old male with a past medical history significant for atrial fibrillation on chronic anticoagulation and stage 3 chronic kidney disease who presents for. That's your introduction. Gives you a quick insight into how sick is this patient? What's their underlying health status? And the key questions that we're looking to answer, can I scope safely? And so the reason they're here, evaluation of rectal bleeding, and then it goes further into their history. When did the problem start? And your mini-review of systems. So he has mild lower abdominal cramping, cramping initially resolved, but then it returned. Giving a little bit of a timing here so that somebody is able to read this and have a quick history. Your mini-review of systems are those additional questions that are pertinent to your chief complaint. How sick is the patient right now? Important things that we would see would be your fever, chills, unintentional weight loss, chest pain, dyspnea, palpitations, dizziness, abdominal pain, nausea, vomiting. And then interval history should have your latest data, the clinical course, recent hospitalizations, any medication changes and new developments. So radiographic findings, critical labs, are they hemodynamically stable? What prior GI evaluation have they had? In the outpatient setting, this is really an important one. If they had seen somebody 10 years ago for the same problem, say somebody came in with GERD and dysphagia and they had an endoscopy 10 years ago and they had a peptic stricture which was dilated, you'd want to include that. Other things that I try to remember, when was the last colonoscopy and what were the findings? Even if they're here for another reason, I think it's important to take the opportunity to do some general health maintenance and screening and education. And so I always try to address, have they had a colonoscopy? If they haven't, why? If they have, when was it and when are they due? In this particular case, the other thing I would want to know is your prior history of rectal bleeding. Is this the first time this has happened or has he had it in the past? And common terminology that you'll see in notes is recent hospitalizations notable for or labs are notable for. In a new patient consultation, your past medical history should be pretty comprehensive. And one of my suggestions would be to make sure that you're doing a thorough chart review and you're really looking at the medications. Patients may not always accurately report their medical conditions or sometimes they think that because they're under good control, like hypertension with their own blood pressure medications, that they no longer have it. We know that they still have it and it may be important if you're, again, talking about sedation in a patient. And so get the history from them and then kind of take a peek back and maybe ask them some questions as you go. Oh, I noticed that you're on metoprolol. Have you been treated for high blood pressure? For the past surgical history, always ask the patients, obviously, but the other thing is to look for incisional scars. They forget and surgery that might've been in their twenties and thirties, somebody who's in their seventies may not always report or remember. So a lot of times I'll say, is this the incision from a gallbladder removal? And then always a word of caution, the electronical medical records are not perfect. And so you really want to make sure that there's not incorrect or incomplete data and that you're doing the best you can to report things accurately. For medications and allergies, prescription medications, Dr. Call had mentioned the importance of a medication reconciliation. Don't always need to know what they've always taken forever and ever, but you do want to know what they're on currently. And in the case of something like elevated LFTs, what were they on the last one month or three months or however long this has been going on for? I think over-the-counter medications is really important for a lot of these patients. So I do specifically ask them about any vitamins, herbal supplements, dietary supplements, and then allergies. And you can kind of separate this in your mind from the true allergies to the intolerances. And it's helpful to specify in the medical record so that when you're making your decisions and making recommendations to the patient, you can use that information to decide whether they would be able to tolerate a medication or not. Latex allergy is important. Some endoscopic equipment will need to be modified if they have a latex allergy. And so I do tend to put that in either bold or red. And so the endoscopist can quickly see that when they see the patients. Social history, you know, talk about tobacco use and do you currently use? And then I like to add, have you ever? Alcohol, how much do you drink? One of the important things with alcohol is that patients may tell you how much they drink, but they may not tell you how big of a glass it is. And so when they say two, they might be really saying it's four. So asking them how large of a glass is important. And then any recreational drugs. For family history, I'm asking them about medical problems in parents, siblings, grandparents. And then I tend to go through a specific list. And so, for example, in this patient, colon cancer is really important. And so I would specifically ask him, do you have any family history of colon cancer or inflammatory bowel disease? Even if he tells me his family history is unremarkable. Another reason why family history is so important is for hereditary cancer syndromes and risk management. And so you want to look for some of these familial diseases so that you can make appropriate recommendations. For your review of systems, your pertinent positives are also often mentioned in your HPI. So this is kind of a mini review of systems. In the 2021 EMM guidelines, you no longer have to have a minimum number of organ systems. And so what they say is basically medically appropriate. Make sure that whatever your problem is you're touching on, but you no longer have to go through that entire 12-system review of system. And so for this patient, the two positives that I highlighted were fatigue and dyspnea, suggestive of maybe some underlying anemia. For a physical exam, you're looking at vital signs and then also your physical exam. Again with the 2021 EMM guidelines for ambulatory medicine, the level of service does not require a minimum number. And so a medically appropriate physical exam is important. And I put the whole thing here more for reference for everybody. He had an irregular irregular rhythm, which was consistent with his history of AFib, but otherwise it was pretty unremarkable. And then medicine imaging is the next part of our note. I like to go newest to oldest, so reverse chronological order so that you can see. I think that it's important to have a comparison for something like this patient where you're talking about rectal bleeding and you want to see what is the trend of his blood work. Especially for older people, sometimes they run at a little bit of a baseline anemia. And then GI procedures, same thing. I like to go reverse chronological order. I think that that can be helpful. Sometimes you'll find procedure information mentioned in prior notes. Other times when they've told me, I'm pretty sure I've had a colonoscopy in 2014 and I can't find a report, I'll go to the surgical pathology in your lab results and I'll start to look there. If there are any biopsies or polypectomies, sometimes I can find it and at least get a date and maybe who did the procedure and then you can kind of backtrack to get the report. For the patient that we're working through today, the last colonoscopy was in 2014. It was normal to the cecum, no polyps or masses were seen and the prep was adequate. We'll talk about the importance of a colon prep later throughout this course, but I like to mention that as well because it may change your decision-making as you're going. And finally, we get to the assessment. For the assessment, you want to briefly restate your HPI intro, report the active issues and the complaints, and then generate a differential diagnosis. The differential diagnosis is the window to your understanding of the patient and the disease process. This is what's going to force you to really think about all the potential causes, not just the one or two most common. And when you think about those causes, it's going to help you to make sure you have a good solid plan. This is a really important exercise and it's something that comes with a lot of time and practice, particularly if you're new to GI, your differential diagnosis tends to be pretty small. And then as you get more experienced, you'll be able to expand upon that and you'll also be able to better outline what's the most likely for this patient. For continuity visits, I do like to put whether the patient's well-controlled, not controlled or poorly controlled. And just an acronym to help with differential diagnosis, you can think of vitamin D. And so when you're thinking about any particular diagnosis, what are the vascular etiologies, infectious, toxic or traumatic, allergic or autoimmune, metabolic or endocrine, iatrogenic, any neoplasms and then drugs. And again, this is more for reference, but I'm a typical, in a note, you could say based on my assessment, most likely diagnosis is hemorrhoids. However, given his age and medical history, we need to exclude other conditions. I think the differential diagnosis is really one of the keys that's going to separate that good APP from the great APP. And so looking back on our case, again, the top is the HPI that we talked about. It includes his recent labs showing acute anemia, symptomatic with fatigue and dyspnea. His last colon was in 2014 and was normal as noted above. If there were significant findings, I would have written them out there. Hemorrhoidal bleeding, infectious diarrhea are the potential diagnoses, but based on his presentation, age, chronic anticoagulation and multiple comorbidities, malignancy and ischemic colitis are also possibilities. IBD is unlikely. And so on the plan, what's the next step of our evaluation? So for this one, we're going to check his blood work again. Looks like he's developing anemia over the period of six months. How quickly is his blood counts dropping? Discussion with the cardiologist regarding your risks and benefits of holding anticoagulation. Dr. Call is going to talk about antithrombotics later in the course, but this is a really essential part of being able to stratify the risk for patients. And then your recommendation, colonoscopy, what kind of sedation do you want? What kind of bowel prep and what are we going to do with his anticoagulation? Instructed the patient to go to the ED if he develops signs or symptoms of anemia. If they start to chemodynamically decompensate, what are they going to do? What are they watching for? And then when should they follow up? If a patient has multiple complaints, I think it's helpful to separate it by problem. So looking at this as a different patient, but somebody who has GERD, well-controlled. Somebody with constipation, not so well-controlled. And what are you going to do for each problem? When you're coding based on time with the new guidelines, you can document time in a single statement. I spent 30 minutes reviewing the patient's diagnostic tests, seeing the patient, talking with the visiting nurse, documenting in the record. You should only count the time that you spend with them on the date of the service. If it's a shared visit, it's the time the APP and the time the physician spends, but you can't double count. If you guys are in the room together for 20 minutes, it still counts as 20 minutes. But if the APP was in 10 minutes beforehand, that's a total of 30 minutes. No burnout. No burnout's a real thing. When I think about this, I am sure that my notes in the beginning of the day are probably better than my notes that I'm doing at 6 p.m. Has nothing to do with the patients. Has nothing to do with the complexity of their medical problems, but it can become very exhausting when you're writing clinic notes all day long. I thought this was an interesting study in clinical gastroenterology and hepatology, which looked at the time that was spent in your electronic health records for ambulatory encounters in GI. And what they ended up concluding is that for each hour of scheduled time, the provider is spending an additional 45 to 50 minutes on your electronic health record related tasks. That's a lot of time. This does not count for your hospital-based work, your direct patient conversation, education, physical exam, and things like that. This was in the Analytics of Internal Medicine, and what they showed is that the amount of time you spend in chart review and documentation was very high. So what can we do to help avoid that burnout? Learn your medical record. Smart phrases, note templates can be very helpful. Dragon, I think, is also a great resource. I felt like I was a fairly proficient typer and that I was doing okay, and I was a bit reluctant to go into Dragon, but I found that Dragon actually helps me to go even faster. The other benefit of it is I think it lets me tell the story better. When you're having a conversation, we explain ourselves a little bit better. You don't want to write too much because you want to be able to have somebody look at it, read it, know what you're thinking and what you're recommending pretty quickly. So you want it to be fairly succinct, but Dragon may help you get there a little bit quicker. Become familiar with any extra features that are available to you. So if you can, in your medical record, customize it with favorites, voice recognition software, things like that, take the time to do so. But I want you to also acknowledge the limitations of these resources. Make sure that what you're doing is for the patient that you're currently working on and that you're not standardizing everything so that you're losing the importance of the individualization. The copy forward function in medical records can help to reduce the time you spend, but you really need to update it and edit it every visit. Any autofill portions of the note, make sure you're reviewing. Like I mentioned in the beginning, sometimes inadequate information or incorrect information is populated and so you'll need to edit that when needed. Try to reduce the volume of your documentation, but really focus on that quality and the accuracy. And so to conclude some of the pearls, you're aiming to retell the patient's story as accurately, efficiently and effectively as you can. A well thought out differential diagnosis is going to really help to separate that great APP and it's going to set the stage for your management plan. Timely note completion and routing to referring provider and PCP is really important. Not only does this help you establish relationships with their referring providers, but really it is important for risk management and for reimbursement reasons. Effective, complete and timely documentation is your best ally and defense against any risk and legal issues, especially with open notes and MyChart messaging. And so I have two polling questions. High quality documentation and patient records is important for all of the following reasons except, good patient care, protection against patient complaints, mitigating medical legal liability, communication with referring providers and the opportunity to educate referring providers. Good. Yeah. So 65% is correct, the protection against patient complaints. As much as we would like to believe that our notes are going to help with that, unfortunately, no matter how good care you provide, how good your note is, we can't always protect ourselves against patient complaints. They could be unhappy for things that are within your control and things that aren't. I think in the era of open notes, a good quality note may help to reduce that, but it's certainly not going to protect you. The second most one, the opportunity to educate referring providers. I really think that your opportunity to do that is in your assessment and plan. When you're talking about why this is most likely, or when you're making recommendations to patients and you're writing them out, referring providers are reading that and that will help them. And the second question, a good assessment and plan and a documented note allows for which of the following? Highlights the most likely diagnosis, suggests reasonable differential diagnosis, outlines the immediate next steps, includes recommendations for follow-up, or all of the above? Exactly. You know, the recommendations for follow-up is one of the things I like to highlight. It's probably the most missed part of an assessment and plan, and questions will come sometimes from either your office staff or the referring provider saying, what next? When do you want to see the patient again? And so that's an important one. As Dr. Call had mentioned, if you don't need to see them again in the office, you can always say follow-up as needed, refer back as needed, but something that indicates that your next steps and follow-up.

high-quality GI note

accuracy

timeliness

patient's care

communication tool

medical necessity