Next, it's my pleasure to introduce Dr. Joe Vaccari. Dr. Vaccari is a practicing gastroenterologist at the Rockford Gastroenterology Associates, which he joined back in 1997, and he firmly served as the managing partner. He currently is clinical assistant professor of medicine at the University of Illinois College of Medicine at Rockford. Dr. Vaccari serves as counselor on the ASGE governing board and is co-chair of ASGE's value of colonoscopy campaign. It's all yours, Joe. It's my pleasure to speak at the course. I'm very grateful for the invitation. And what I'd like to do today in this lecture is really follow up on Jill's comments. And there'll be a little overlap, but I think that it's fine to have some overlap when talking about creating a quality note. I've been practicing GI for 25 years. I'm still learning and looking for ways to create that better note. So from the big picture standpoint, we'll review the key components of a high quality note, outline some key information to include in the GI note, and this can apply both to those working inpatient, outpatient, or in a hybrid model, and then offer some tips and strategies to improve our efficiency and really reduce ways to avoid note burnout, especially in the day of the EMR where we have so many variables coming our way. Big picture view of the talk, we want to create with a quality note an accurate and timely record of the patient's care. Our goal is to tell a good story and develop a good impression and management plan. It's also a communication tool between us as GI providers, our referring physicians, the PCPs. It's also an opportunity to teach PCPs about GI and also helps us with ancillary services. As Jill pointed out, it justifies the medical necessity of services rendered. I really won't be saying anything about reimbursement, but the note we create does justify those services. It demonstrates the standard of care was met. We'll hear comments later in this conference about medical legal risks, and this is by creating a quality note is a good way to begin mitigating risk management, and again, it supports the build level of service. Okay, I'm not going to go into detail at the moment on all of these points. You're all familiar with the components of the HNP, or in our case, the GI consult, but we will break down the important ones and dive deeper into how to create that quality note. Unique to GI, since we are both a cognitive and procedural specialty, some other things to consider putting in different components of your note. Can the patient give consent? That's an important point for non-immersion procedures. Does the patient need any special accommodations? Are they a difficult IV stick, and do they need to arrive earlier for their appointment? We'll hear about anticoagulation and antithrombotic management during the talk, and then some other unique things. Is the patient a Jehovah's Witness? And if they're having a GI bleed, we want to make sure we follow their wishes for no blood product transfusions. The chief complaint is the reason for the consult in the patient's own words. And I think that's an important point. What is the patient telling you as to why they are seeing you? In this case, we'll start off with the chief complaint from the patient. I'm passing blood mixed with stool for three days. Very short statement, but it tells us a lot. They're bleeding, and for the duration that they are bleeding. The next section is the history of present illness. William Osler, the father of internal medicine, said many years ago, or the father of modern day internal medicine, said if you give him a good history of present illness, that he could make the diagnosis in the overwhelming majority of the patients. So the history of present illness is that introduction to the patient's problem, and it is the purpose for what we're ultimately trying to put together. We'll go over a nice acronym called OLD CARDS to help us think through creating a good history of present illness. The history of present illness also contains a mini review of systems, specifically those signs and symptoms that are pertinent to why the patient is seeing you. And it's also an opportunity for an interval history to update the GI history, again, especially with pertinent labs and other items that we'll discuss. For the intro portion of the history of present illness, obviously age, sex, major medical problems. So a nice example, very brief. This is a 72-year-old male with a past medical history significant for atrial fibrillation on chronic anticoagulation, stage 3 kidney disease, who presents four. So we're setting up that this patient has some chronic illnesses, may be somewhat sick before we dive into telling the GI story. So how is this helpful? First, if we're thinking this patient needs a procedure, and let's assume this is a patient that had the rectal bleeding and the chief complaint, I have to ask myself, can I scope the patient safely? What do I do with the anticoagulation? What do I do with the anticoagulation? And if I can scope the patient safely, when can I scope the patient? Is the patient short of breath? Are they hypoxic? Are they getting dialyzed today? Is this emergent or non-emergent procedure? So the chronic illnesses help us determine what we can do in GI. And in GI, obviously, we do a lot of invasive procedures. So OLD CARTS, I think this is a really nice acronym to help us think about preparing a good story in the history of present illness. So let's take abdominal pain, for example. When did the abdominal pain start? Where is L for location? Where is it located? Right lower quadrant, left lower quadrant. Duration, how long is it? Is it seconds, minutes, or hours? Minutes or hours. What is the character of the pain? Is it sharp? Is it dull? Is it cramping? Aggravating factors. Is it worse after a meal? Relieving factors. Does it improve with a meal? Does the abdominal pain improve after a bowel movement? Timing and severity. Mild, moderate, severe, or any other type of scale you'd like to use to define severity. I find this very helpful. I use it often to create my history of present illness. It's an easy acronym to remember. So let's continue building our story. 82-year-old male. Past medical history significant for atrial fibrillation. On chronic anticoagulation with Xeralto. CHF with an ejection fraction of 15%. COPD on two liters. We're really creating a nice healthy patient. And CKD stage three who presents four. Evaluation of rectal bleeding. He was in his usual state of health until three days ago when he developed mild, low abdominal cramping. After 30 minutes, he had an urgent bowel movement with bright red blood mixed with stool. Cramping initially resolved but returned within one hour. Now having three to five bowel movements per day. Previous baseline one to two. Stool mixed with bright red blood. Not taking any antidiarrheal medications. Denies any correlation to oral intake. So we're starting to build our story. We have our chief complaint. We have our old cards working through the story. And since we are specialists, the story should be concise. Keep it as concise and accurate as possible. The next step that we'd like to think about within the HPI is adding that mini review systems. And these are additional questions which are pertinent to the chief complaint and pertinent to the patient's story. As we brought in some non-GI issues in this case with cardiac disease and COPD, it really can tell us how sick the patient is. And in the case of doing endoscopic procedures, as I said, when can we proceed and when can we proceed safely? Some non-GI review systems to bring in might be fever and chills if we're worried about a patient with cholangitis. Unintentional weight loss with change in bowel habits and GI bleeding. And as we pointed out, cardiopulmonary are the big ones. Chest pain, dyspnea, dizziness, shortness of breath. Because if patients need endoscopic procedures, as you all know, they will undergo some form of sedation and analgesia. And it's very important that we bring in our GI pertinent positives and pertinent negatives such as nausea, vomiting, abdominal pain, blood in the stool, and other items that help us tell an accurate story. The interval portion of the history of present illness. This is where we should be looking at the latest data, looking at any recent clinical hospitalization of the recent clinical course as an outpatient, any medications, anything that has changed recently in their health care. So we would want to bring this into the HMP at this point, and this may include CT of the abdomen and pelvis. It could include important labs such as CBC if there's GI bleeding, hepatic function panel if we're looking at a patient with LFTs, and in the case of GI bleeding, perhaps hemodynamics, and any prior GI evaluation. That prior GI evaluation mostly will look at the endoscopic procedures and pathology related to the prior GI evaluation. As it relates to prior GI evaluation, important questions to ask are when was the patient's last colonoscopy as it relates to our current case, what were the findings, any pathology related to that, and in this case, is there any prior history of GI bleeding? Are there items you may want to bring in if they've been hospitalized recently? Try to bring in some of the notes or data from those notes, and again, any labs that are important. We'll quickly move through some of the other items. Jill had mentioned some of these. Past medical history is obviously a comprehensive list of their medical problems. The most important to us tend to be cardiopulmonary problems, those of which we would bring into the HPI. It's another opportunity for us to do a chart check, understand whether the chart and data is accurate. A nice way to see if the past medical history is accurate is compare the past medical history to their medication list. If there are some inaccuracies, then you may have to start doing some homework. I know my own experience, sometimes patients will come in, the data is incomplete. I see they're on three or four medications for heart disease, and they don't tell me much about their heart history, so it's a nice way to double check on the history. Also ask about past surgical history. This could have implications for perhaps making a colonoscopy more difficult in a patient that's had a hysterectomy, a cholecystectomy. It might be nice for the endoscopist to know those details. And if you can't get an accurate history, it's always easy to look at the abdomen and look for scars to see for prior surgeries. Again, as you look through your history, it's really important to look for incorrect, and more importantly, incomplete data from the patient. And also, that reflects perhaps an incomplete database in the EMR. So look for ways to double check, especially looking that the medications correlate with their past medical history. Medications. Obviously, we want an up-to-date medication list. And for endoscopy, it's important we understand if there are any anticoagulants or any thioperidines, such as Plavix. When we talk to patients about medications, we need to be clear. Medications include prescription medications, over-the-counter medications, herbals, and I even throw in any family remedies that they use. If we just ask for medications, we might only get their prescription medication. So look at these other items that could impact how we treat and perhaps side effects for the patient. Allergies. I think the most important thing for us to distinguish a true allergy, which is angioedema, which is significant, hives, rash, sore throat, anaphylaxis, versus what many people tell us, oh, doc, or I'm allergic to NSAIDs. They make me nauseous. That's an intolerance. I'm allergic to morphine. It gave me constipation. So we need to differentiate a true allergy, because that takes us down one path and perhaps a very important path, person intolerance, where we may consider still using the medication or picking another medication perhaps in that class. Latex allergy is important to list. We don't see much latex used these days. Tobacco. Cigarettes can have an important, cigarettes, tobacco, chewing tobacco are important. Cigarettes in patients with IBD are important. Did they use them? Are they using them now? Have they ever used them? Alcohol is always the tricky one. About half my practice is liver disease. If you ask someone how much they drink, I think we're all familiar with, especially those who have alcohol problems or alcohol-related liver disease, they tend to underestimate what they drink. Just as important, we really need to understand how large a glass is or how much they're drinking. I can't tell you how many times I've asked a patient, how many beers do you drink a day? They say three. I say 12 ounces, no. I say 16 ounces, they say no. I say 48 ounces, they say yes. In their mind, that's three drinks. In our mind, that's a very different number. And how often did they drink? Look for illicit drugs, cocaine, IV drug use for viral liver disease, and ask if it's current or past use. Marijuana is a different question these days. In many states, it's legal. In some states, it's illegal. In Illinois, it's legal. It's important to ask about marijuana use, especially in patients, young patients who come in with nausea and vomiting. There is cannabinoid hyperemesis. Actually, we see a fair amount of it in our practice, so make sure you ask about marijuana use, how much. If you're thinking that this could be cannabinoid hyperemesis, ask them one simple question. Do they take a hot shower and doesn't make them feel better? I don't know that there's any science behind that, but that tends to be a tip-off that this could be cannabinoid hyperemesis. Ask for family history. Ask patients about their family history or medical problems. Most importantly, their primary relatives, their mom, dad, brothers, and sisters. That's especially important for colon cancer, however. Using colon cancer as an example, if mom had colon cancer and mom's mom had colon cancer, that's also important to know. Or perhaps mom had colon polyps, her mother had colon cancer, and her maternal aunt had colon cancer. Don't be afraid to build that family history tree as we're thinking about certain GI diseases. Also, ask about, again, get into the details of any past family history medical problems. Family history, review it. Here's an example. Notable for colon cancer in mother at age 62. No pertinent family history of inflammatory bowel disease, liver disease, pancreatic disease, or celiac disease. A very quick way to put together family history that could impact the diagnosis that you start to put together. Review of systems. We talked about pertinent positives, pulling them into the history of present illness, and also look at ways to bring in the pertinent negatives when they're important. For review of systems, pertinent positives, something like fatigue in people with liver disease. Look at these other important ones again. I know I'm being repetitive, but I think it's important. Cardiovascular, pulmonary are the most important pertinent positives and negatives to bring in when they're appropriate. Vital signs, most important, the hemodynamic status of our patients that have GI bleeding, heart rate, are they tachycardic, are they bradycardic, do they have a normal heart rate? Are they hypotensive? Are they newly hypotensive? Then for our physical exam, we really want this to be a focused physical exam. In addition to the vital signs, general things, do they look their stated age? Do they appear to be in distress? Patients with liver disease, are they jaundice? Do they have ichthyrus? Pulmonary and cardiac exam, again, important if we're thinking about sedation and analgesia. For extremities, do they have edema as we think about our liver patients? As we also think about our liver patients, are they alert? Are they oriented? Are we worried about encephalopathy? So try to keep our exam focused in GI. Those broader, more detailed exams are important for general medicine, but in GI, we want to keep things focused as we start to tell a more focused, detailed story. It's also important to bring in our labs. Some of the labs, as we talked about earlier, will bring into the history of present illness. You can also put the labs in a separate section if you wish, or put them in both places. I like to put them both places. So it's important to include other relevant data, labs, imaging studies, and in this case, I think it's important to present in a reverse chronological order. So the patient presents today, our patient presented today with rectal bleeding. Their hemoglobin today was 9.4. Three months ago, it was 10.7, and five months ago, it was 11.7. So this tells us that the labs have been trending down, and then we can start to put together our impression and plan as it relates to this patient with GI bleeding. So I think it's best to put those together in reverse chronological order. Same thing with our images. If we have a patient who had an ultrasound of the abdomen a year ago and had cholelithiasis, but no other findings, and now they come in with right eye quadrant pain, and their ultrasound shows not only cholelithiasis, but there's a dilated common bile duct. So it's nice to compare to the baseline, and also I think it's best presented in reverse chronologic order. The same applies to the GI procedures. Best to present these in reverse chronologic order. When we bring in our GI procedures to our history of present illness, and again, when we talk about impression, you may bring those back in, make sure you also bring in pathology results. If they are relevant, and present in reverse chronologic order. For example, last colonoscopy was in 2014, and was normal to the cecum. So in our patient with rectal bleeding, this is important to know that the last exam was in 2014, and all was normal, and the preparation was also good. As I said, reviewing, you can put that in the history of present illness. Another good way to find this data is to look for prior notes, whether they be hospital-based notes or clinic-based notes. It may be a quick way to find this information, and also a quick way to summarize many data points instead of going through each section in your EMR, and where it's important to look at any surgical pathology. Assessment. As we start to put together our assessment, we're starting to tell another story. This second story starts with a brief restatement of the history of present illness. It's where we summarize, again, the active issues, and we start to generate a differential diagnosis. As we generate our differential diagnosis, this helps us formulate and present our evaluation, and ultimately develop our management plan. I look at generating the differential diagnosis as an opportunity to really show off. This is where you can really show off your cognitive skills. It's your ability to think. My uncle worked for IBM, and on his desk, he had a sign that said, Think. That was IBM's motto. I really think that should be our motto in medicine and specifically in GI. So as you develop your differential diagnosis, put a lot of thought into it. It's your chance to shine, to complete the story, and really develop a quality note and develop a quality plan. For those visits that are continuity visits, it's important, if you want to briefly tell the story or summarize the story, are their symptoms controlled and they're doing well? Have they had some decompensation in the disease and they're not controlled, or are the symptoms poorly controlled and we really need to think about a new management plan? Another acronym that I like, Vitamin D. I think it helps us formulate a good differential diagnosis and tell the end of our story. So as you work through your differential diagnosis, we can, again, use abdominal pain. Vascular, is this abdominal pain vascular in etiology? Could the etiology be infectious? Infectious, I. T, toxic or traumatic. A, allergic or autoimmune. M, metabolic or endocrine. I, iatrogenic. N, neoplasm. And D, drugs. Again, a very simple acronym to remember, and it really keeps you thinking. After 25 years, I still think of these acronyms. They keep me honest, they keep me sharp, and it gets me thinking about the patient's problem. So some language you might see as you put together the differential diagnosis and how you put together your differential diagnosis. Whether you like a list, whether you like a paragraph, whether you're a minimalist with words like I am or like one of my partners, it tends to be a longer story. It really doesn't matter. It's how you prefer to tell a story and tell it effectively. So for this example, based on my hour assessment, if I'm working with one of our nurse practitioners, the most likely diagnosis is X. However, given her age and medical history, we need to exclude other conditions such as Y, Z, and so forth. It's extremely unlikely that A is in the differential diagnosis. In this case, based on my hour above assessment and after discussion with the patient, we developed the following plan. So summarize the story, go through the differential diagnosis, put that together in whichever way you feel comfortable, but just make sure it tells a good story. So this is a 72-year-old male with a past medical history, significant for atrial fibrillation, on chronic anticoagulation, Xarelto CHF, COPD, and stage 3 kidney disease. Presents for evaluation of abdominal cramping and rectal bleeding. Recent labs demonstrate acute anemia, symptomatic fatigue, and dyspnea on exertion. Last colonoscopy was in 2014 and was normal as previously noted. Very nice summary in our impression. Here's our differential diagnosis. Hemorrhoidal bleeding and infectious diarrhea are potential diagnosis. However, based on his presentation, age, chronic anticoagulation, and multiple comorbidities, malignancy, and ischemic colitis are also possibilities. IBD is unlikely. It doesn't matter if any of these are right or any of these are wrong. It doesn't necessarily matter if my partner, Dr. Shields, agrees with me or doesn't. I'm thinking. I'm putting together a story, ultimately trying to get to the right answer. And if you think through your differential diagnosis, you will come up with the answer over 99% of the time and ultimately develop a very good management plan. So as we start to develop our management plan, it's really our opportunity to outline the steps and the next steps in our evaluation. In this particular case, based on my assessment and after discussion with the patient, we developed the following plan. Update CBC in one week. Discussion with cardiologists regarding risks, benefits of holding anticoagulation in a setting of rectal bleeding and new anemia. Colonoscopy under moderate sedation with a murlax prep. Xarelto can be discontinued if deemed high risk to hold by cardiologists. And I think this is an important point. You'll see more on anticoagulants later in this talk. But we really should be making the decision in conjunction with the cardiologist, not on our own. We discussed with the patient colonoscopy is generally a safe procedure. How are risks included? The following. Patient understands and is agreeable to proceed. Instruction patient to go to the ER if developed signs and symptoms of anemia. And follow up in GI clinic four weeks after colonoscopy completed. This is the story that we put together. Your story could be a little different. It could be shorter. It could be longer. Again, style is less important than putting together an accurate impression and plan that completes our story. One last item as it relates to putting the end of the story together, if a patient does have multiple complaints, I find it helpful to really break them out, trying not to tell the story in too many ongoing sentences and paragraphs. Again, I'm a minimalist with terminology. So my breakdown of multiple complaints might look like this. 56-year-old male with past medical history significant for hypertension and hyperlipidemia who presents for follow up of GERD and chronic constipation. So I would then break down the GERD into bullet points. GERD will develop controlled on PPI, review dietary and lifestyle modifications, discuss the child tapering of PPI, patient had concerns about staying on a PPI long term. So we discussed that tapering, constipation, persistent despite dietary changes. And I have those recommendations that were made. The point is, in this slide, really just to say if they have multiple GI complaints, I think it's much more effective and tells a better story to break those down. Note burnout. Burnout is something I will talk about more. And so I'll just make a brief few comments about note burnout. The EMR is very helpful in many ways. But as I said earlier, it brings together a lot of variables. We are all bombarded with data in the EMR. Somehow it seems like we have more paper coming to us in a time when we should have less paper. So there's a lot to go through. Ways we can try to avoid note burnout when we're developing our note is to really learn your EMR. Try to understand the smart phrases and understand how you can effectively and efficiently use those in your note. Develop templates. You can develop your own templates that are unique to you. You can collaborate with other physician and APPs in your group to develop templates. We essentially have group templates, although some will tell theirs to their personal liking. So look at ways that you could develop templates that can improve your efficiency. I love using Dragon NaturallySpeaking for medicine. It's really effective. It's very efficient. I find that speaking to develop my notes is more efficient than typing. However, you may find out that typing is more efficient. Some of our nurse practitioners find that typing is more efficient than speaking. So find out which is better for you. Most importantly, become familiar with any and all features that are available to you within your EMR and make sure you set up favorites, take advantage of voice recognition, and perhaps sit down with your local expert with your EMR to have even a meeting for half hour an hour to really try to find some of the tricks that you can use to take advantage of your EMR. Also acknowledge the limitations of these resources. And so no one template may be good for everybody. Again, take time to develop things for yourself so you can individualize the note for your liking. Copy forward is a function that is helpful. I do use it, but I think we need to be careful. It certainly can help us reduce time when creating a note, but we really need to pay attention to update it and edit it at every visit. I get a little obsessive compulsive when I use the copy forward. I want to make sure the date is correct, the time is correct, that all the information is correct. I find it helpful to copy forward especially when I'm at the hospital, especially at the hospital on the weekends when I'm by myself. But you do have to pay attention to the accurate update of information, especially reviewing auto fill portions of the note. This does help to reduce your documentation volume. You're not cutting and pasting perhaps from note to note, but we still need to emphasize quality and accuracy in our notes. Overall, as we start to think about avoiding note burnout, everything we do, we want to document better, document more efficiently and effectively to create a quality note, but not create note burnout. Some practice pearls to talk about. Again, we are telling a story and our goal is to retell the patient's story in different words so it accurately, efficiently and effectively portrays and communicates their story. The history of present illness is so important and a well thought out differential diagnosis is also important. I think it's your chance to shine and I think it's a way to separate the great APP from the average. We have superstar APPs in our practice and when they give me their impression, I know I'm getting an accurate impression, a well thought out differential diagnosis and I know I can really trust that information to go and see the patient and develop a quality note and quality plan. Timely note completion and referring those notes to the provider is really important. You don't want to go days and days without note completion. It's not good for communication and it's not good for other variables. So timely note completion, important for good patient care, establishing and maintaining relationships with referring providers. Good notes reduce our medical legal risk and as Jill pointed out are important for reimbursement. Risk management, we'll get more about that, but it's effective, complete and timely documentation is your best ally and defense against risk and legal issues. Tell the story, tell it accurately, document accurately. Okay, following question number one, high quality documentation in the patient record is important for all of the reasons except good patient care, protection against patient complaints, mitigating medical legal liability, communication with referring providers and an opportunity to educate referring physicians. Excellent, the correct answer is protect against patient complaints. All the other bullet points are correct. We could be the nicest person in the world, do the best job with the patient and as we all know in all of life, we cannot always please everyone. A good assessment and plan in a document note allows which of the following, highlight most likely diagnosis, suggest reasonable differential diagnosis, outline immediate next steps for evaluation and management, includes recommendations for follow up, all of the above. There you go, Dr. Bakeri. Perfect, I really enjoyed this talk and really the goal is to get everybody to think, communicate effectively and you all have the skill sets to create great notes. So thank you for the opportunity to speak to you.

gastroenterology care

quality note

patient's care

comprehensive management plan

communication tool

electronic medical record

note completion