ASGE Annual GI Advanced Practice Provider Course - Onboarding Day One (On-Demand)

Video Transcription

Video Summary

In this video, Dr. Joe Vaccari discusses the key components of creating a high-quality note in gastroenterology. He emphasizes the importance of documenting an accurate and timely record of the patient's care, as well as ensuring effective communication with referring physicians. Dr. Vaccari provides tips and strategies to improve efficiency and reduce note burnout in the era of electronic medical records. <br /><br />He suggests using acronyms like OLD CARTS (onset, location, duration, character, aggravating factors, relieving factors, timing, and severity) and VITAMIN D (vascular, infectious, toxic/traumatic, allergic/autoimmune, metabolic/endocrine, iatrogenic, neoplasm, and drugs) to guide the development of a thorough history of present illness and differential diagnosis. He also emphasizes the importance of documenting relevant data such as labs, imaging studies, and previous GI procedures in a reverse chronological order.<br /><br />Dr. Vaccari highlights the need to individualize notes, become familiar with EMR features, and utilize templates and copy-forward functions cautiously. He encourages timely note completion and emphasizes the role of quality documentation in patient care, risk management, communication, and reimbursement.<br /><br />Overall, Dr. Vaccari's talk provides practical guidance on creating effective and efficient gastroenterology notes.

Asset Subtitle

Joseph Vicari, MD, MBA, FASGE

Keywords

high-quality note

gastroenterology

patient care

effective communication

electronic medical records

thorough history

timely note completion