ASGE Annual GI Advanced Practice Provider Course - Day One | July 2021-Presentation 2 -Creating a Quality GI Note

Video Transcription

Video Summary

In this video, the speaker discusses the key components of a high-quality GI note. They emphasize the importance of accuracy and timeliness in documenting the patient's care. The note serves as a communication tool between the GI provider and other healthcare professionals, as well as a record of the patient's care. It also justifies the medical necessity of the services provided and ensures that the standard of care was met. The speaker highlights important information to include in the note, such as patient consent, contact information, accommodation needs, antithrombotic and diabetic management, and any underlying concerns or preferences. They go through the different sections of a GI note, including the chief complaint, history of present illness, past medical history, medications and allergies, social history, review of systems, physical exam, medical imaging, and GI procedures. The speaker also provides tips to increase efficiency and reduce note burnout, such as using smart phrases, note templates, and voice recognition software. They stress the importance of quality documentation for good patient care, communication with other providers, risk management, and reimbursement. Overall, the video provides a comprehensive guide to creating a quality GI note. No credits were granted in the video.

Asset Subtitle

Sarah Enslin, PA-C

Keywords

high-quality GI note

accuracy

timeliness

patient's care

communication tool

medical necessity