Key Highlights

Recommendations for individual emergency physicians, nurse practitioners, and physician assistants:

• A concise, clinically pertinent summary of prior records is sufficient to meet coding requirements for medical decision-making. Importing large volumes of documentation from prior records is not additive and contributes to note bloat.
• A concise summary or discussion of results of labs and or radiology tests ordered and/or reviewed by the emergency physician or NP/PA is sufficient to support coding requirements for medical decision-making. Pulling extensive amounts of lab results or complete radiology reports into a note is not additive compared to a concise summary.
• While attestation language depends on the type of note, the type of supervision, and federal, state, and institutional rules, in general, a succinct statement indicating the presence and role of the attending physician in the patient’s care is adequate for attestation. A separate documentation of history, exam findings, medical decision-making or other elements of the supervisee’s note is redundant and potentially discrepant, opening the chart to confusion among readers.

Recommendations for ED leadership and hospital-based information technology (IT) departments:

• Emergency physicians and NP/PAs should be instructed on the utility, risks, and expectations of CIT. EHR tools facilitating the import of content from results or chart elements can, if used indiscriminately, contribute to note bloat without improving reimbursement or reducing medicolegal risk.
• Clinical informaticists and institutional IT departments should play a major role in developing approved, system-wide documentation templates and appropriate CIT, reviewing the quality of templates and CIT already in use, and instructing emergency physicians and NPs/PAs on responsible use. In addition to personalized feedback to emergency clinicians on the quality of their documentation, EHR reports should expand to include CIT usage. Department-endorsed standardized note templates and in-line clinical decision support on appropriate documentation should be employed to guide EM clinicians on structuring their clinical notes.
• Note content derived from CIT (such as macros, dotphrases or copy/paste) should be easily identifiable in clinical notes, to support review and validation by the note authors, and let readers understand where CIT was employed.

The sweeping, once-in-a-generation reforms to E/M coding rules planned for January 1, 2023 use medical decision-making (MDM) instead of elements from history of present illness, review of systems, and physical exam to determine the level of service.

Medical decision-making largely depends on the complexity of the patient’s presentation, risk to the patient, and thought processes related to testing and interventions considered or performed. You might be tempted to meet the MDM criteria by importing data into the note, like past medical history, medications, lab, and imaging tests ordered and reviewed. Don’t do it! Those elements are (or should be) visible to clinicians and coders in other areas of the chart. Importing all this data into the note itself will change medical decision-making from a useful distillation of a clinician’s thinking, into a litany of items available elsewhere.