Providers severely lack early documentation instruction, according to Erica Remer, MD, the director of an intensive medical documentation course at Cleveland-based Case Western Reserve University School of Medicine.
Here are her recommendations for producing high-quality documentation, as published on ICD10 Monitor.
1. Read the E&M guidelines for yourself. Rely directly on the guidelines, which detail general principles of E&M documentation and how it relates to codes. Note E&M documentation is about quality, not quantity.
2. Make the documentation work for you and the patient. Documentation should contain valuable details of the patient's circumstances. Only copy and paste information if it advances patient care — don't do it just to increase the volume of documentation.
3. Focus on medical decision-making. The current push to revise E&M requirements and place medical decision-making at the forefront could be beneficial, Dr. Remer said, as long as history and physical requisites aren't completely eliminated.
4. Recruit EMR experts. EMR experts in your organization or office can "help you leverage the EMR to assist you, not impede you," Dr. Remer said. Good templates, accurate smart phrases and voice recognition could be beneficial.
5. Consider using a scribe. Using a scribe can free up a provider to spend more time face-to-face with patients. Several studies have shown scribe services increase provider productivity and improve patient and provider satisfaction.