ASGE Annual GI Advanced Practice Provider Course - Onboarding Day One (On-Demand) | July 2021-02

02_Creating a Quality GI Note-Enslin

Pdf Summary

This document provides guidelines for creating a high-quality gastrointestinal (GI) note. The objectives of a quality note include accurately documenting patient care, facilitating communication between providers, justifying medical necessity, demonstrating the standard of care, and supporting billing. The key components of a high-quality GI note include the chief complaint, history of present illness (HPI), medications/allergies, personal and family medical history, review of systems (ROS), physical exam, labs/imaging, assessment, plan, and follow-up recommendations. The HPI should include the onset, location, duration, character, aggravating and relieving factors, timing, and severity of symptoms. The ROS and physical exam should be thorough and relevant. Labs and imaging should be included as necessary, and prior GI procedure history should be referenced. The assessment should include a differential diagnosis, and the plan should outline next steps and follow-up. Time spent on EHR-related tasks can contribute to note burn-out, so strategies to increase efficiency include utilizing smart phrases, note templates, dragon dictation, and extra features in the EMR. Copy-forward functions can save time but should be updated and edited. Quality documentation is essential for patient care, communication, risk management, and reimbursement. It is important to tell the patient's story accurately, efficiently, and effectively. A good assessment and plan should highlight the most likely diagnosis, suggest differential diagnoses, outline immediate next steps, and include follow-up recommendations.

Keywords

gastrointestinal note

patient care

communication between providers

medical necessity

standard of care

billing support

chief complaint

history of present illness

medications/allergies

personal medical history