Consult and clinic notes are an important part of patient care, and it is crucial to complete these notes efficiently and effectively. Here are my suggestions for those who are just starting out.
1. Help convey the patient’s story.
All notes need a documented “chief complaint” — why is the patient here? For the history of present illness (HPI), document what you feel is important: pertinent positives and negatives (guided by the chief complaint) are excellent to document.
You may have been told in the past that you need four elements of a “PQRST” history — but this is no longer a billing requirement (see tip No. 4). Stay focused on the patient’s complaints and build your pertinent story.
2. Communicate your findings to other providers.
When someone reads your note, they scroll first to the assessment and plan. Consider formatting your note in APSO (assessment, plan, subjective, objective) order, putting the assessment and plan at the top of the note.
In your assessment, clearly indicate your diagnoses, additional workup and treatment recommendations. Do not just keep listing an updated plan for each day; summarize when appropriate.
DO NOT USE ACRONYMS. Each specialty has its own dictionary that is foreign to other specialties. Our “PVD” for a posterior vitreous detachment can easily be confused with peripheral vascular disease. Use the power of the electronic health records (EHR). You can still use your acronyms, but your EHR can transform it immediately into the fully spelled-out acronym. Now everyone can read and understand your notes.
3. Remind yourself of the details of the patient’s course and treatment.
Use your notes to help you! You put a lot of thought into each patient encounter — don’t let your hard work go to waste. Put down your thoughts to jog your memory. What is your goal intraocular pressure (IOP) for that patient? If their IOP does not come down, what is your planned next step? By clearly stating these in your notes, it makes your follow-up appointments go smoother and allows your subsequent documentation to be quicker.
4. Master your billing.
We bill based on what we do, and we use the EHR and notes to document what we do. There are two types of billing codes: eye visit codes and evaluation and management (E/M) codes.
Eye codes can only be used in outpatient clinics and are usually based on the number of exam elements: 3 to 11 exam elements for an intermediate eye code, and all 12 exam elements for a complete eye code. Visit the Academy’s cheat sheet for eye visit codes to learn more.
Forgetting to document your confrontation visual field can drop your billing from a level 4 comprehensive code to a level 2 intermediate code.
E/M codes were revised for outpatient (2021) and inpatient (2023) to focus more on medical decision- making than counting note elements (like family and social history). There are certain billing “points” that you accumulate by documenting things you already do. Document which notes you reviewed to help obtain your HPI and if you received elements of the HPI from a person other than the patient (like a spouse). Record which labs and images you reviewed.
With good, clear and efficient documentation, everyone wins. And you get a perfect “10.”
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Evan Silverstein, MD, is the 2023 chair of the
YO Info editorial board. He specializes in pediatric ophthalmology and serves as assistant professor and associate program director at Virginia Commonwealth University in Richmond, Va.