How To Make Provider's Notes Simple, To The Point & Compliant

The implementation of Electronic Health Records (EHRs) introduced a documentation model that often included cloned or copied, cut-and-pasted sections, leading to voluminous notes with unnecessary information. This practice made it challenging for physicians to locate crucial details about patient care.

Recent changes in documentation guidelines have shifted the focus away from counting bullet points to a more intuitive approach. In 2021, the AMA restructured documentation rules for office and outpatient Evaluation and Management (E&M) services. Subsequently, in 2023, the rules for other E&M service codes were aligned with the 2021 guidelines.

These changes aim to make physician documentation more intuitive, emphasizing the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications and/or mortality and morbidity of patient management.

This webinar, with Industry expert, Jill M. Young, CEMA, CPC, CEDC, CIMC, will discuss these changes and provide tools to help providers understand and implement the new guidelines effectively. Specifically, Jill will define five key elements needed for creating a good, compliant note.

Webinar Objectives

The objective of this webinar is to emphasize the importance of clear, concise, and compliant documentation for office visits. Often, in the process of inserting text, the rationale and reasoning behind a physician's actions can be overlooked or lost. Our goal is to help providers make their notes simple, to the point, and compliant, ensuring that all necessary information is included and easily accessible.

Webinar Agenda

• Each of the three areas of the Table of the elements of medical decision making will be reviewed. 
• Compliant documentation of each of the three columns of the table will be discussed.
• The top five of items needed for a good note will be identified

Webinar Highlights

• Documentation tips for compliant documentation of the number and complexity of problems addressed at the encounter
• Documentation tips for compliant documentation, the amount and complexity of data to be reviewed and analyzed
• Documentation tips for compliant documentation the risk of complications and/or mortality and morbidity of the patient management
• Key documentation phrases for visits that are incident to or split shared
• Identifying five things needed for good, efficient, compliant documentation of an office visit

Who Should Attend

Billers, Auditors, Office and Practice Managers, Physicians