Documentation for emergency physicians - Revision history

Rossdonaldson1: /* Special Documentation */

2026-03-25T20:41:50Z

Special Documentation

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	==Special Documentation==		==Special Documentation==
	*[[Critical care documentation]] — required for billing critical care time (CPT 99291/99292)		*[[Critical care documentation]]: required for billing critical care time (CPT 99291/99292)
	*[[Observation documentation]] — required for observation-status patients		*[[Observation documentation]]: required for observation-status patients
	*[[Against medical advice]] — capacity assessment and risk discussion		*[[Against medical advice]]: capacity assessment and risk discussion
	*[[Discharge documentation]] — discharge instructions, follow-up, return precautions		*[[Discharge documentation]]: discharge instructions, follow-up, return precautions
	*[[Death documentation]] — time and pronouncement of death, family notification		*[[Death documentation]]: time and pronouncement of death, family notification
	*[[Informed consent documentation]] — procedural consent elements		*[[Informed consent documentation]]: procedural consent elements

	==Billing==		==Billing==

Rossdonaldson1: /* Key Principles */

2026-03-25T20:41:12Z

Key Principles

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	==Key Principles==		==Key Principles==
	*~~'''~~If you didn't document it, it didn't happen~~''' —~~ standard medicolegal axiom		*"If you didn't document it, it didn't happen" is not true, but is a standard medicolegal axiom
	*Document ~~the~~ clinical reasoning, not just the diagnosis		*Document
	*~~Document all discussions~~ with patients, families, consultants, and PMDs		**The clinical reasoning, not just the diagnosis
	*~~Document '''time~~-sensitive~~'''~~ findings (e.g., time of stroke symptom onset, time antibiotics given in [[Sepsis\|sepsis]])		**Discussions with patients, families, consultants, and PMDs
	*~~Always document~~ [[Against medical advice\|AMA]] discussions thoroughly including capacity assessment		**Time-sensitive findings by time (e.g., time of stroke symptom onset, time antibiotics given in [[Sepsis\|sepsis]])
	*~~Document reassessments~~ before [[Discharge documentation\|disposition]]		**[[Against medical advice\|AMA]] discussions thoroughly including capacity assessment
			**Reassessments before [[Discharge documentation\|disposition]]

	==Components of the ED Medical Record==		==Components of the ED Medical Record==

Rossdonaldson1: /* Background */

2026-03-25T20:39:14Z

Background

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	*The ED medical record serves as a legal document, communication tool, and billing justification		*The ED medical record serves as a legal document, communication tool, and billing justification
	*Poor documentation is the most common reason for malpractice verdict against the physician, even when clinical care was appropriate<ref>Self TH, et al. The importance of documentation in medical malpractice cases. J Pharm Pract. 2010;23(6):526-531.</ref>		*Poor documentation is the most common reason for malpractice verdict against the physician, even when clinical care was appropriate<ref>Self TH, et al. The importance of documentation in medical malpractice cases. J Pharm Pract. 2010;23(6):526-531.</ref>
	*~~'''~~Document in real time~~'''~~ whenever possible; retrospective documentation is less accurate and less credible		*Document in real time whenever possible; retrospective documentation is less accurate and less credible
	*As of 2023, CMS E/M coding for ED visits is based primarily on ~~'''~~medical decision making (MDM)~~'''~~ or ~~'''~~total time~~'''~~, no longer requiring specific history/exam element counts for billing level<ref>American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Other (Inpatient/Observation) Services Code and Guideline Changes. 2023.</ref>		*As of 2023, CMS E/M coding for ED visits is based primarily on medical decision making (MDM) or total time, no longer requiring specific history/exam element counts for billing level<ref>American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Other (Inpatient/Observation) Services Code and Guideline Changes. 2023.</ref>

	==Key Principles==		==Key Principles==

Danbot: Major expansion: added Background, Key Principles, structured components, special documentation links, billing section, references, documentation pages template

2026-03-24T10:55:44Z

Major expansion: added Background, Key Principles, structured components, special documentation links, billing section, references, documentation pages template

@@ Línea 1: / Línea 1: @@
-==Sample Documentation==
+==Background==
-===General===
+*Thorough documentation is essential for patient safety, medicolegal protection, and appropriate reimbursement
-*[[Review of systems documentation]]
+*The ED medical record serves as a legal document, communication tool, and billing justification
-*[[Physical exam documentation]]
+*Poor documentation is the most common reason for malpractice verdict against the physician, even when clinical care was appropriate<ref>Self TH, et al. The importance of documentation in medical malpractice cases. J Pharm Pract. 2010;23(6):526-531.</ref>
-*[[Differential diagnosis documentation]]
+*'''Document in real time''' whenever possible; retrospective documentation is less accurate and less credible
-*[[Procedure sample documentation]]
+*As of 2023, CMS E/M coding for ED visits is based primarily on '''medical decision making (MDM)''' or '''total time''', no longer requiring specific history/exam element counts for billing level<ref>American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Other (Inpatient/Observation) Services Code and Guideline Changes. 2023.</ref>
-===Special Time===
+==Key Principles==
-*[[Critical care documentation]]
+*'''If you didn't document it, it didn't happen''' — standard medicolegal axiom
-*[[Observation documentation]]
+*Document the clinical reasoning, not just the diagnosis
-===Special Discussions===
+==Components of the ED Medical Record==
-===See Also===
+===History===
 *[[Residency: Basic Skills]]
-==Billing Discussion==
+{{Documentation pages}}
-*[[Billing]]
 [[Category:Documentation]]

TannerLeeFrey: /* General */

2021-11-19T08:32:46Z

General

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	*[[Reexamination sample documentation]]		*[[Reexamination sample documentation]]
	*[[MDM for different chief complaints documentation]]		*[[MDM for different chief complaints documentation]]
	*[[CMS criteria for charting]]

	===Special Time===		===Special Time===

TannerLeeFrey: /* General */

2021-11-19T01:45:32Z

General

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	*[[Reexamination sample documentation]]		*[[Reexamination sample documentation]]
	*[[MDM for different chief complaints documentation]]		*[[MDM for different chief complaints documentation]]
			*[[CMS criteria for charting]]

	===Special Time===		===Special Time===

TannerLeeFrey: /* General */

2021-11-19T01:18:19Z

General

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	==Sample Documentation==		==Sample Documentation==
	===General===		===General===
			*[[Review of systems documentation]]
	*[[Physical exam documentation]]		*[[Physical exam documentation]]
	*[[Differential diagnosis documentation]]		*[[Differential diagnosis documentation]]

Avisiani: /* General */

2021-05-13T23:05:06Z

General

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	*[[Procedure sample documentation]]		*[[Procedure sample documentation]]
	*[[Reexamination sample documentation]]		*[[Reexamination sample documentation]]
			*[[MDM for different chief complaints documentation]]

	===Special Time===		===Special Time===

Rossdonaldson1: /* See Also */

2020-07-01T22:02:04Z

Chungirv: /* Sample Documentation */

2017-08-10T17:57:29Z

Sample Documentation

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	===Special Discussions===		===Special Discussions===
	*[[Against medical advice]]		*[[Against medical advice]]

			===See Also===
			[[Residency: Basic Skills]]

	==Billing Discussion==		==Billing Discussion==

← Revisión anterior		Revisión del 22:02 1 jul 2020
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	===See Also===		===See Also===
	[[Residency: Basic Skills]]		*[[Residency: Basic Skills]]

	==Billing Discussion==		==Billing Discussion==