ASGE Annual GI Advanced Practice Provider Course - Onboarding Day One (On-Demand) | July 2021-Presentation 2 -Creating a Quality GI Note

Video Transcription

Video Summary

In this video, the speaker discusses creating a quality gastrointestinal (GI) note. They review the key components of a high-quality note, including important information to include for both inpatient and outpatient notes. They also touch on new billing requirements and provide tips to increase efficiency and reduce note burnout. The speaker emphasizes the importance of a quality note, noting that it serves as a communication tool between GI providers and other healthcare providers, justifies medical necessity, and supports the level of service billed. They provide examples of information to include in the note, such as patient consent, contact information, antithrombotic and diabetic management, underlying patient concerns, and religious preferences. The speaker also discusses sections of the note, such as the chief complaint, history of present illness, past medical history, medications and allergies, and family history. They provide guidance on documenting physical exams, medical imaging, and GI procedures. The video concludes with strategies to avoid note burnout and the importance of timely and accurate documentation.

Asset Subtitle

Sarah Enslin, PA-C

Keywords

gastrointestinal note

quality note

billing requirements

note burnout

medical necessity

timely documentation