Efficient and Effective Charting

Summary of Urgent Care Boot Camp lesson: Efficient and Effective Charting

If you're like me, you hate charting, yet it is a crucial part of our job as our competence of care is judged by our charts

Why do we chart?

• Communication
• Billing & coding
• Medicolegal

Before you put anything in the chart, ask if it fulfills any of these objective. If it doesn’t leave it out! Do not spend the same amount of time on each pt chart. Spend more time/chart more for higher risk complaints/patients (e.g. chest pain, abdominal pain, extremes of ages)

Communication

• The MDM and plan are most read by other clinicians
• Always include a medical decision making (MDM) note--this is important for cases which bounce back
• MDM needs to be succinct summary of: thought processes/differential, provisional diagnoses, plan
• Complete your MDM while caring for pt—this serves as checkpoint to ensure you’ve thought through all your differential diagnoses

Billing and coding

• Accurately capture the work that you do. (FYI—this is also important when asking for a raise..it captures revenue you bringing in)
• Know which E&M codes to use—is this a new pt? Established? 99201 versus 99214 visits are reimbursed very differently
• Do not forget about procedural code--these include laceration repairs, I&Ds, applying splints, EKGs, interpreting x-rays, counseling pts, coordinating care. You take the risk of carrying out procedures, do not forget to get reimbursed for it

Medicolegal

• Do not practice defensive medicine—think twice before shot gunning labs/imaging that creates more risk than benefit. Instead, create a chart that is defensible
• Document you’ve considered dangerous/emergent conditions
• Disposition should fit the pts presentation—Discharged pts should have reassuring HPI/physical exams. If pt is sent to ED, management should reflect worst first
• Document adequate care was provided while in clinic
• Document arranged adequate follow up/return instructions

Be sure to check out Urgent Care Boot Camp by HippoEd! Did you learn something new? Have any more charting tips?