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91. Is this the end of note bloat? | Breaking down the 2023 documentation guidelines

Nov 7, 2022

The podcast discusses the upcoming changes in documentation guidelines for coding, billing, and compliance, highlighting the burdensome nature of the current guidelines. They emphasize the potential for the new guidelines in 2023 to reduce the burden of documentation and allow clinicians to prioritize patient care. The importance of real-time documentation in the emergency department and the value of capturing the ED course are also discussed. The chapter also explores the process of importing radiology reports into a patient's chart and the challenges of reconciling independent interpretations. Additionally, the podcast highlights the importance of documenting the consideration of escalation or de-escalation of care and discusses the disagreement between the American Medical Association and CPT regarding guidelines for critical care time in 2023.

01:06:15

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Quick takeaways

The upcoming changes to documentation guidelines for clinicians will shift the focus to medical decision-making and reduce unnecessary history and exam documentation.

The new documentation guidelines highlight the importance of documenting social determinants of health, which can lead to policy changes and improved patient care and outcomes.

The value of documenting independent interpretation of images or studies, as well as obtaining information from non-patient sources, helps support continuity of care and provides a comprehensive view of patient care.

Deep dives

Transition to New Documentation Guidelines

The podcast episode discusses the upcoming changes to documentation guidelines for clinicians, specifically emergency clinicians. The current guidelines are considered burdensome and lead to unnecessary documentation. However, the new guidelines, set to be implemented in 2023, aim to focus on medical decision-making rather than extensive history and exam documentation. The guidelines emphasize the importance of medically appropriate history and exam, as well as addressing comorbidities and risk stratification. These changes aim to reduce note bloat and allow clinicians to focus on what truly matters in patient care.

Focus on Medical Decision-Making in EMR

01:20

Capturing Encounters for Better Alignment

01:55

Documenting Rationale in Differential Diagnosis

00:53

Understanding Medical Decision Making Levels

02:23

Introduction

5min

Changes in Documentation Guidelines and the Impact on Clinicians

20min

Streamlining the Job Search Process and External Record Review in Documentation Guidelines

4min

The Importance of Real-time Documentation in the ED

23min

Importing radiology reports and reconciling independent interpretations

3min

Documenting Escalation or De-escalation of Care

10min

Disagreement on Critical Care Time and Guidelines for 2023

2min

28 years ago, the die was cast for how emergency department encounters were documented. Since then, we've had note bloat, click fatigue, and too much attention placed on things that really didn’t matter. All of that is slated to change in 2023 with dramatic new documentation guidelines (that today’s guest calls ‘refreshing’) are implemented. When was the last time you heard the word ‘refreshing’ used when it came to charting? And a massive thank you and hat tip to my friend Matt DeLaney who now runs ERcast - he was the first to alert us to these guidelines and interviewed Jason when they were first announced.

Guest bio: Jason Adler, MD is a clinical assistant professor of emergency medicine at the University of Maryland where he is also the director of compliance and reimbursement. He is also the vice president of acute care solutions at LogixHealth.

Episode Sponsor: Ivy Clinicians. Curious if there’s a better clinical opportunity out there? Ivy is the simplest way for physicians, PAs, and nurse practitioners to match with jobs they love. With Ivy, you can find all 5,549 emergency departments, filter by your preferences, and connect securely with the right employers. All for free.

For full show notes of this episode and all sorts of other goodies, visit our podcast website

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We Discuss:

History and physical documentation are now at your discretion;
Heavy value is placed on cognitive work and medical decision making;
History from a non-patient source is valued in these guidelines;
Ordering a test is equally valued as not ordering a test;
Consideration of escalation or deescalation of care;
In addition to documenting your shared-decision making conversations, your MDM should include;
Population health - Stable means something different when it comes to documentation;
Social determinants of health;
There is a heightened emphasis of independent interpretations of separately billable procedures (EKGs, X-ray, CT, U/S);
Jason’s take home points;
And More.

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Stimulus - Learn Tools to Crush It in Your Medical Career

91. Is this the end of note bloat? | Breaking down the 2023 documentation guidelines

Podcast summary created with Snipd AI

Quick takeaways

Deep dives

Transition to New Documentation Guidelines

Acknowledging Social Determinants of Health

Importance of Independent Interpretation and Relevant Information

Valuing Documentation and Meaningful Medical Records

Evolving Guidelines and the Shift towards Quality Medicine

Focus on Medical Decision-Making in EMR

Capturing Encounters for Better Alignment

Documenting Rationale in Differential Diagnosis

Understanding Medical Decision Making Levels

The Flameproof Course

Remember Everything You Learn from Podcasts