documentation, a guide for new doctors, here we go

documentation, a guide for new dowctors

1. Documentation: A Guide for New Doctors Katie Stanton-Maxey, MD, FACS

2. Why is this important? Documentation is the record of your patient’s history and care It assists others who are providing care for your patient It provides the basis for which you, and your facility, obtain payment for services rendered.

3. But I already know how to write an H&P. How much do you actually know about documentation guidelines/requirements? Basics for all E/M services documentation: Complete and legible Reason for encounter Relevant history Physical exam findings Prior diagnostic tests Assessment/clinical impression (diagnosis) Plan of care Should also include: Health risk factors Patient’s progress- response to & changes in treatment

4. I don’t know anything about ‘E/M’ Evaluation and Management codes represent services furnished during a clinical encounter Codes are selected based on 3 factors: Patient type Setting of the service Level of service performed Level of service is determined by 3 components: History Examination Medical decision-making

5. Chief complaint required HPI elements Location Quality Severity Timing Modifying factors Associated signs/symptoms Past, Family, Social History Pertinent = one item from any three areas Complete = 2 or all 3 areas History Brief 1-3 elements Extended 4+ elements ROS Problem pertinent = only about the system of the problem Extended = 3-9 systems (including the problem) Complete = 10 systems (including the problem)

6. Examination General Multi-System Examination Single Organ System Examination

7. Medical Decision Making Consider: # and types of problems Complexity of establishing a diagnosis Management decisions Discussion is required Based on: Presenting problem(s) diagnostic procedure(s) Possible management options 1 2 3 1 2 3 *see example chart in the doc

8. Application What do we need now?

9. H&P Time it! Include all components for a ‘detailed’ document Include pertinent data ONLY Problem list WITH diagnoses Clinical reasoning and decision making THE PLAN “staffed with…”

10. Progress Note Use SOAP format! Overnight events & patient’s subjective statement Only pertinent data Brief physical exam Problem list with diagnoses Clinical reasoning and decision making Plan for the day & expectations DO NOT copy paste exam or out of date info

11. Orders Get to know the EMR Ordersets Useful to standardize care Beware of need for exceptions/changes Everything on it has your name Always refer back to a pneumonic

12. Prescriptions Rarely on paper anymore Necessary components are same Comply with e-prescribing signups and guidelines

13. Discharge Summary Dates of admit & d/c Attending & team Consultants Procedures w/dates Brief HPI Brief hospital course Exam on discharge Condition at discharge Medications Instructions Follow up Discharge issues

14. PITFALLS Medications New meds Potential problems Who is in charge Changes to existing Those discontinued Dose changes Instructions Diet Activity Bathing? Wounds Who to call for problems When to seek urgent care Don’t forget the family/caretakers Follow up Surgeon PCP Consultants Other Therapies Wound care