ASGE Annual GI Advanced Practice Provider Course - Onboarding Day One (On-Demand) | April 2022-02_Creating a Quality GI Note

02_Creating a Quality GI Note - Vicari

Pdf Summary

Creating a quality GI note is essential for accurate and timely patient care, communication with referring providers, justifying the medical necessity of services rendered, demonstrating that standard of care was met, and supporting the billed level of service. Key components of a high-quality GI note include the chief complaint, history of present illness, medications/allergies, past medical history/past surgical history/family history, review of systems, physical exam, labs/imaging/GI testing, assessment, and plan. The note should also consider patient consent, accommodations, and antithrombotic management if a procedure is recommended. Efficient note writing can be achieved by utilizing smart phrases, note templates, voice recognition software, and updating and editing copy-forwarded information every visit. Emphasizing quality and accuracy over quantity can help reduce documentation volume. Additionally, a well-thought-out differential diagnosis and a timely completion and routing of notes to referring providers/PCPs are important for good patient care, establishing relationships, risk management, and reimbursement. Good documentation also protects against patient complaints, medicolegal liability, and provides an opportunity to educate referring providers. By following these strategies, healthcare professionals can create quality GI notes that enhance patient care and streamline the documentation process.

Keywords

quality GI note

patient care

communication

referring providers

medical necessity

chief complaint

history of present illness

physical exam

assessment

differential diagnosis