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01-11-2021 | Viewpoint

Rethinking What Is Essential in the Office Visit Note

Authors: Stephen D. Persell, MD, MPH, Heather L. Heiman, MD

Published in: Journal of General Internal Medicine | Issue 11/2021

Excerpt

The new ambulatory documentation rules from the Centers for Medicare and Medicaid Services (CMS), which took effect on January 1, are far from the most dramatic medical news of this new year.¹ But these changes, which significantly update long-stagnant documentation requirements for office-based evaluation and management visits, deserve attention and applause. The rules attribute trust and value to the cognitive reasoning of the outpatient physician, and they may allow office visit notes to better serve the needs of physicians, patients, and colleagues. …

Centers for Medicare and Medicaid Services. 42 CFR Parts 403, 409, 410, 411, 414, 415, 416, 418, 424, 425, 489, and 498 (November 15, 2019)

American Medical Association. CPT® Evaluation and Management. Available at https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management. Accessed December 31, 2020.

Sinsky C, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice: a Time and Motion Study in 4 specialties. Ann Intern Med. 2016;165(11):753-760. doi: https://doi.org/10.7326/M16-0961.CrossRefPubMed

Holmgren AJ, Downing NL, Bates DW, et al. Assessment of Electronic Health Record Use Between US and non-US Health Systems. JAMA Intern Med. 2021;181(2):251-259. doi: https://doi.org/10.1001/jamainternmed.2020.7071.CrossRefPubMed

Martin SA, Sinsky CA. The map is not the territory: medical records and 21st century practice. Lancet. 2016;388(10055):2053-2056. doi: https://doi.org/10.1016/S0140-6736(16)00338-X.CrossRefPubMed

Office of the National Coordinator for Health Information Technology (ONC), Department of Health and Human Services (HHS). 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program. 85 FR 25642. Published May 1, 2020. https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-cures-act-interoperability-information-blocking-and-the-onc-health-it-certification. Accessed April 10,2021.

Mangalmurti SS, Murtagh L, Mello MM. Medical Malpractice Liability in the Age of Electronic Health Records. N Engl J Med. 2010;363(21):2060-7. doi: https://doi.org/10.1056/NEJMhle1005210.CrossRefPubMed

Title: Rethinking What Is Essential in the Office Visit Note
Authors: Stephen D. Persell, MD, MPH
Heather L. Heiman, MD
Publication date: 01-11-2021
Publisher: Springer International Publishing
Published in: Journal of General Internal Medicine / Issue 11/2021
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI: https://doi.org/10.1007/s11606-021-06860-z

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