ASGE Annual GI Advanced Practice Provider Course (Virtual) - Onboarding (Day One) | March 2023-Creating High-Quality GI Consultation

Pdf Summary

In this document, the author discusses the key components of a high-quality gastrointestinal (GI) consultation note. The author emphasizes the importance of accurate and timely documentation in patient records for various reasons, including good patient care, protection against patient complaints, mitigating medico-legal liability, communication with referring providers, and the opportunity to educate referring providers.<br /><br />The components of a high-quality consultation note are outlined, including the chief complaint (CC), history of present illness (HPI), medications/allergies, past medical history (PMH), physical examination (PE), labs/imaging, assessment (including a differential diagnosis), and plan. The HPI should include the patient's own words regarding their symptoms, as well as relevant information such as onset, location, duration, character, aggravating and relieving factors, timing, and severity.<br /><br />Other important elements of the note include a mini review of systems (ROS), interval history (which includes recent hospitalizations, medication changes, and prior GI evaluation), family history, and a brief summary of the patient's vital signs and physical examination findings.<br /><br />The assessment section should include a differential diagnosis, using the "VITAMIN D" acronym as a guide (Vascular, Infectious, Toxic/Traumatic, Allergic/Autoimmune, Metabolic/Endocrine, Iatrogenic, Neoplasm, Drugs), and the plan should outline the next steps in evaluation and management, including any recommended follow-up.<br /><br />The author also provides tips and strategies to increase efficiency and reduce note burn-out, such as utilizing smart phrases, note templates, and voice recognition software. The importance of reducing documentation volume while emphasizing quality and accuracy is emphasized.<br /><br />Lastly, the document mentions the potential role of artificial intelligence (AI) in improving documentation and consultation services requirements, such as referrals, providing opinions, and generating reports.<br /><br />Overall, the document serves as a guide for creating a high-quality GI consultation note, highlighting the key components, strategies to improve efficiency, and the importance of accurate and timely documentation for patient care, communication, and risk management.

Asset Subtitle

Joseph Vicari, MD, MBA, FASGE

Keywords

gastrointestinal consultation note

high-quality

documentation

patient care

medico-legal liability

referring providers

differential diagnosis

efficiency

artificial intelligence

risk management