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Clinic Note


Practicefirst would like to share a short summary of the six ways to evolve the clinic note. This is a part of the white paper that was a collaborative effort between AMA and Nordic. The white paper in its entirety can be found at https://www.ama-assn.org/system/files/2021-03/ama-em-updates-physician-note-white-paper.pdf


1. Remove unnecessary information and duplication: Physicians should only include relevant information in their notes, incorporating specific results when appropriate or simply referencing them in summary form.


2. Embrace the encounter report: Today, many vendors have a concept of an encounter or visit report, which can be thought of as a grouping of building blocks, each of which brings in certain data points relevant to the visit. The encounter report can be stored statically when the physician closes or signs off on the visit, thereby representing a holistic accounting of what happened.


3. Upend the SOAP note with the APSO format: Given the way most EHRs function, it can make sense to put the assessment and plan part of the note at the top (APSO). This format allows clinicians to quickly scan notes and find the information that is most frequently being sought. APSO formatting creates more usable notes by presenting essential information in ways that make it more easily consumed.


4. Add documentation for time…. if appropriate: If time is to be used to calculate the E/M code, physicians should include all the time they spend associated with that visit on the day of the encounter. Besides face-to-face time in the exam room or online chat, this includes prep time and work after the patient is seen. Note that there is no requirement to document the time spent if the physician is not using time to calculate the appropriate E/M code.


5. Consider the patient as the audience: Physicians should consider the patient when they are writing notes. Technical language may still be-appropriate, of course, but it may be prudent to avoid potentially confusing abbreviations


6. Focus on The Why: While many members of the clinical team can and should contribute to the ambulatory progress note, the physician alone is responsible for creating and documenting the assessment and plan. Physicians are solely responsible for The Why. Leverage the EHR to collect and display The What (e.g., vital signs, smoking status, orders entered, and medications changed). Ensure that the tools needed by physicians to document the assessment and plan are available, such as voice recognition and common templates.

 

For Coding questions, please contact our Coding Managers, Vidya Baliga at vidyab@pracfirst.com and Kelly Cole at kellyc@pracfirst.com or at 716-389-3262.


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