Maximizing Charting Points

Several years ago I spent a couple of hours with our head coder to come up with a macro that would make us “compliant” with all the “points” that billers care about. I don’t remember what “points” are, but I know that when I use this macro I get a lot of RVU’s out of each chart. It’s also helpful for a quick summary at the end.

As with all of these, this is a work in evolution. If you have a way to make this better, please let me know or put it in the comments below.

ED Summary:
@NAME@ #@MRN@
@VSAMB@[CC]: @CHIEFCOMPLAINTN@

@AGE@ @SEX@ ***

ED Work-Up

  • ***Laboratory: significant for ***
  • ***Radiology: significant for ***
    • ***spoke with radiology resident.
    • ***I reviewed films myself
  • ***EKG: significant for ***
  • ***Medical Records: ***significant for ***
  • ***Critical Care Time: *** minutes, spent assessing patient, speaking with consultants and family, reviewing results, and outside of procedures
    • System at risk: ***

Communications

  • Consultation: ***
  • PMD: @PCP@ ***notified/paged

***Resident Attestation:
I have interviewed and examined the patient. I have reviewed and agree with the resident’s History/Physical and Assessment/Plan unless noted as highlights, additions, deletions and/or addendums – see above. Ten ROS performed, unremarkable except as noted.

***Nurse Practitioner Attestation Note
I have seen and examined the patient and have formulated the assessment and plan as documented above.

Disposition

***Admission: patient’s medical condition, safety or health would be threatened if care was provided in less intensive setting due to: ***

  • ***severity of signs and symptoms
  • ***potential adverse outcome
  • ***unstable condition
  • ***need for further diagnostic studies
  • ***co-morbidities or extenuating circumstances
  • ***failure of outpatient treatment

***Obs Status:

  • event: ***
  • with plan to *** and eventual treatment goal of ***.

@WETREAD@

@EDLABS@

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Maximizing Charting Points

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