Clinical documentation has evolved considerably over the years, reflecting the influence of technology and various health care stakeholders. Physician notes have evolved from short and succinct handwritten (but often illegible) prose to pages of electronic drivel. Modern ED documentation should concisely describe clinical presentations and communicate medical decision making without sacrificing reimbursement or increasing liability. With the new E/M coding changes upon us, it’s incumbent on ED leadership, hospital IT, and billing and coding staff to work together to make our notes clear and uncluttered.
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ACEP Now: Vol 41 – No 12 – December 2022When that complicated patient returns to your ED starting in January, newer ED notes are a lot easier to read. There’s no more scrolling through countless rows of computer-generated prose about review of systems and exam. Your department has worked with IT and billing and coding to curtail the wholesale import of past history and results, because coders can find that info elsewhere. The MDM section is clear and succinct, only listing pertinent positives and material relevant to clinical communication for today’s ED visit.
Dr. Genes is director of emergency medicine informatics at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health.
Dr. Baker is an emergency physician at Pali Momi Medical Center in Aiea, Hawaii.
Dr. Heaton is an emergency physician Rochester, Minnesota, and practices at Mayo Clinic Rochester.
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