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Documentation

  • Lesson Learned: Delayed Documentation Can Lead to Suspicion

    The Case A 33-year-old woman presented to the emergency department with shortness of breath. She checked into...
  • Patients Will Soon Have Access To Clinical Notes—Are You Ready?

    Patient records have been around for millennia. Evidence from antiquity shows that medical records initially functioned as...
  • The Cures Act Gives Patients Access To Our Notes, & This Could Be Good

    The Office of the National Coordinator for Health Information Technology (ONC), a staff division of the U.S....

Lesson Learned: Delayed Documentation Can Lead to Suspicion

October 19, 2021 - Eric Funk, MD - 1 Comment

The Case A 33-year-old woman presented to the emergency department with shortness of breath. She checked into…

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Patients Will Soon Have Access To Clinical Notes—Are You Ready?

March 23, 2021 - Indira Gowda, MD; and Nicholas Genes, MD, PhD - 0 Comment

Patient records have been around for millennia. Evidence from antiquity shows that medical records initially functioned as…

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The Cures Act Gives Patients Access To Our Notes, & This Could Be Good

March 23, 2021 - Kenneth Alan Totz, DO, JD, FACEP - 3 Comments

The Office of the National Coordinator for Health Information Technology (ONC), a staff division of the U.S….

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Relaxed Documentation Burden for Teaching Physicians

August 11, 2020 - Michael Lemanski, MD - 0 Comment

As part of Centers for Medicare & Medicaid Services (CMS) efforts to reduce mandatory and duplicative documentation…

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How to Maximize Reimbursement for Advanced Practice Provider Services

October 15, 2019 - Jason Adler, MD, FACEP - 0 Comment

Question: How can we maximize reimbursement for services provided by advanced practice providers? Answer: “Non-physician provider” (NPP),…

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Inconsistent Records & Insufficient Imaging Complicate Malpractice Case

September 24, 2019 - Eric Funk, MD - 0 Comment

Patients often present to the emergency department with multiple symptoms that do not fit clearly into one…

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ACEP Continues Working to Decrease Your Documentation Burden

September 18, 2019 - ACEP Now - 0 Comment

On Aug. 12, ACEP responded to a CMS request for information on additional ways to reduce the…

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Coding Wizard: How To Get Paid for Point-of-Care Ultrasound

July 21, 2019 - David Friedenson, MD, FACEP - 0 Comment

Question: How can I be reimbursed for performing and interpreting my bedside point-of-care ultrasound (POCUS)? Answer:  According…

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Coding Wizard: How to Document an IV Fluids Requirement

June 20, 2019 - Tyler W. Barrett, MD, MSCI, FACEP - 0 Comment

Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar…

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How to Document Exams Performed by Advanced Practice Providers

July 10, 2018 - Michael Lemanski, MD, FACEP, FAAFP - 0 Comment

Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar…

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