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

02_Creating a Quality GI Note - Vicari

Pdf Summary

Creating a high-quality gastrointestinal (GI) note is essential for accurate patient care and communication. A quality note should include key components such as the chief complaint, history of present illness (HPI), medications and allergies, past medical history (PMH), review of systems (ROS), physical exam findings, labs/imaging, assessment, and plan. It is also important to consider patient consent, any necessary accommodations, and antithrombotic management. The HPI should include the patient's own words for the chief complaint, along with information on the onset, location, duration, character, aggravating and relieving factors, timing, and severity. The HPI should also include relevant information from the mini ROS and interval history. The PMH, PSH, medications, and allergies should be thoroughly reviewed and documented. Family history should be noted, along with any pertinent positives in the ROS. The physical exam should include relevant findings and be presented in reverse chronological order. Labs, imaging, and prior GI procedure history should be included, along with any pathologic/cytologic results. The assessment should generate a differential diagnosis and outline the next steps in the evaluation. The plan should include instructions for follow-up and any necessary referrals. Tips for increasing efficiency and reducing note burn-out include learning the electronic medical record (EMR), using smart phrases and templates, and becoming familiar with additional features available. It is important to focus on quality and accuracy rather than volume in documentation. Lastly, timely note completion and communication with referring providers is important for patient care, medico-legal risk mitigation, and reimbursement. In summary, creating a quality GI note involves accurately documenting key components, considering additional factors, and implementing strategies to improve efficiency and reduce burn-out.

Keywords

gastrointestinal note

patient care

communication

chief complaint

history of present illness

medications

allergies

past medical history

review of systems

physical exam findings