Think in
Ink!

Thoughtful and thorough clinical documentation is critical to achieve accurate acuity measurement and full reimbursement.  With the elimination of H&P and ROS in the determination of E/M service level under the 2023 E/M Guidelines, detailed medical decision documentation has become even more important.

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MDM “tells the story” of a patient’s ED visit.  If any part of the story is left out, then it cannot be used in determining the E/M service level.  Anyone reading the encounter documentation should be able to clearly understand:

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• Why the patient presented to the ED

• What you were concerned about and what you considered

• What you did to address those concerns

• How the patient responded to your management

• Your disposition and final recommendations

The following elements are critical to be documented for E/M services under the 2023 E/M Guidelines:

Problem

• Differential diagnoses ruled out based on testing or other considerations

• Chronic illnesses that impacted the care provided

Data

• Review of prior external records from a non-ED source (make sure to identify the source)

• Diagnostic tests appropriately considered, even if not ultimately performed.

• Assessment that is obtained from an independent historian

• Independent interpretations

• Discussion of test interpretation with external physician

• Discussion of management with other providers

Risk

• Recommendation to patient of OTC drugs at discharge

• Prescription medications appropriately considered, even if not given.

• Appropriate consideration of admission or escalation of care

• Care that is affected or limited by social determinants of health

• Application of evidence-based risk calculators

• Patient’s response to treatment

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