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The Framework
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Probably the best means to gain an understanding of the suggested framework for the creation of documentation is via understanding the organization within the E&M Coder. Even if it is not intended to actually use the E&M Coder, the framework it utilizes is likely to be the best organization for documentation in the future.
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1. With Summary info staying on the Summary side, in the future, when I (or the insurance company, or a lawyer) look back on this date, there is no documentation of what Past medical, family, surgical, social history I considered in making my decision. That could be an issue medico-legally. Also, the Coder counted the Summary items, but if the payor wants documentation to justify my code I can send them a: copy of the note only, which doesn't show any PMH, or b: an extended note, with summary, which may contain data added since the visit, and thus does not accurately represent the work done that day (which may constitute fraud).
2. A note as thorough as your example (e30.jpg) is great for justifying charges (with the caveat above), but to be very useful clinically there must be a way to make the most pertinent points stand out. (Hardly anybody will read that much info).
Andy
The text in the ST items can be changed to be shorter or abbreviated to suit individual preferences. Usually, it is a simple right-click... Manage SMARText Items... Edit SMARText item and change the text in the Header section for that ST item. In our starters, we have to avoid abbreviations and more stylized-shortened descriptions.
With a little practice, most users should be able to have the text in their documentation appear just about exactly as they prefer, yet have the option (in the background) for it to actually be uniquely identified, searchable-retrievable data items of far greater value than the gobbilty-goop of the past. edited 05:41, 18 Feb 2008