ASGE Annual GI Advanced Practice Provider Course (On-Demand) - Onboarding (Day One) | March 2023-Creating High-Quality GI Consultation

Pdf Summary

In this document, Dr. Joseph Vicari discusses the importance of creating a quality GI consultation. He outlines the key components of a high-quality note and offers tips to increase efficiency and reduce note burn-out.<br /><br />The key components of a high-quality GI consultation note include:<br />1. Chief Complaint (CC): This should be the reason for consultation in the patient's own words.<br />2. History of Present Illness (HPI): This includes the onset, location, duration, character, aggravating factors, relieving factors, timing, and severity of the patient's symptoms.<br />3. History: This includes the patient's past medical history, past surgical history, family history, and social history.<br />4. Physical Exam: This includes relevant findings from the patient's physical examination.<br />5. Labs/Imaging: This includes any pertinent laboratory or imaging results.<br />6. Assessment: This includes a differential diagnosis and an assessment of the most likely diagnosis.<br />7. Plan: This includes the steps for further evaluation and management, as well as recommendations for follow-up.<br /><br />To create a high-quality GI consultation note, Dr. Vicari suggests using strategies to increase efficiency, such as learning the electronic medical record (EMR) system, using smart phrases and note templates, and utilizing voice recognition software. He emphasizes the importance of reducing documentation volume while still emphasizing quality and accuracy.<br /><br />Dr. Vicari also mentions the role of artificial intelligence (AI) in improving documentation and notes the requirements for consultation services, including referral, providing an opinion, and reporting the findings to the referring provider.<br /><br />In conclusion, creating a quality GI consultation is essential for accurate and timely documentation of patient care, communication with other healthcare providers, justifying medical necessity, demonstrating adherence to the standard of care, and supporting appropriate reimbursement. By following the outlined components and utilizing efficiency strategies, healthcare providers can enhance the effectiveness and efficiency of their consultation notes.

Asset Subtitle

Joseph Vicari, MD, MBA, FASGE

Keywords

GI consultation

quality note

efficiency

note burn-out

chief complaint

history of present illness

history

physical exam

labs/imaging

assessment