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.
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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.
