It is safe to say that documentation in the electronic health record (EHR) era has become burdensome. ACP is aware of these concerns and is working to ensure that the 2021 changes to the E/M codes help relieve some of the burden, as well as make it easier to understand documentation and utilize it while seeing a patient.
ACP and the HIMSS Electronic Health Record Association (EHRA) Clinician Experience Workgroup cohosted “EHRA & ACP E/M Summit: State of the Note” on April 9. The summit aimed to develop a unified set of guidance and best practices for clinical documentation in response to the recent 2021 E/M coding changes. Before the summit started, the group established a common understanding of how the E/M guidelines changed documentation, then outlined an agreed upon set of draft best practices or principles for clinical documentation.
The goal of the collaborative work was to identify answers to such questions as:
- How much detail is necessary without adding additional documentation burden and “note bloat”?
- Is there any information that is less important and thus can be dropped from the note?
- How can a clinician balance clinical language with patient-friendly language?
The summit discussions began with an overview of the E/M changes and were followed by breakout, small-group sessions to learn, share, and evaluate E/M coding guidance. The groups worked on distinguishing between the “good” and “bad” in an example note and developing a consensus “good note,” with all efforts toward making recommendations to minimize burden in documentation and make use of the E/M changes. The goal was for physician and vendor groups to come to a consensus and publish best practices and principles.
The summit participants also agreed on a list of do's and don'ts for the primary care note. Generally, the note should focus first on pertinent clinical details relevant to the history of present illness (HPI) that are useful and valuable to other team members or clinicians for the care of the patient. The assessment and plan should tell the story of the patient's situation (including social and medical challenges) and explain the medical decision making in a way that can be understood by the patient.
Other elements of the record, such as chief symptom, physical exam, and patient instructions, should be included only when relevant and where they add clinical value to the patient's story. Because patients will see the note, abbreviations should be used carefully or explained up front.
Last, some things can be dropped from the note or documented elsewhere. For example, any relevant findings in the review of systems or medical history sections would be included in the HPI or assessment and plan. Likewise, the clinician only needs to track time spent on the day of the patient encounter in the EHR. Time does not need to be added to the note.
If these practices and principles are successfully adapted, the result should be a return to a more concise record that includes only what is needed to tell the patient's story and is written in clear language that both a team member and a patient can understand. To see the best practices document that was created during this summit, please visit ACP's E/M Coding page.