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Doctor talking to distressed patient

Account for Social Determinants of Health When Coding Office Visits

By Dr. Michael Warner
In health information management
Nov 1st, 2020
Comments Off on Account for Social Determinants of Health When Coding Office Visits
In 2021, external factors affecting patient health weigh in on medical decision making. The American Medical Association’s 2021 medical decision making (MDM) grid for outpatient/office evaluation and management (E/M) services is particularly innovativ...
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Electronic medical health record.

Guidelines for Clinical Documentation Improvement

By Dr. Michael Warner
In CMS
Sep 1st, 2020
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Guidelines for clinical health record documentation changes in ...
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Woman entering her prehistory in computer health record.

How Patient Prehistories Improve Health Outcomes

By Dr. Michael Warner
In Evaluation Management
May 1st, 2020
Comments Off on How Patient Prehistories Improve Health Outcomes
Ensure providers have the information they need, before they need it. At the point of triage, patients and family members are typically asked a series of medical interview/history questions. At this juncture, however, staff members do not have the lux...
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Nurse with tablet speaking to patient in waiting room.

Take the Training Wheels off EHR Systems

By Dr. Michael Warner
In Evaluation Management
Apr 2nd, 2020
Comments Off on Take the Training Wheels off EHR Systems
Electronic health records (EHRs) are a major reason for physician burnout and job dissatisfaction. But they are about to improve the healthcare experience for physicians, ancillary medical staff members, and patients. Now’s the time to take off the ...
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customer service

Capture the Patient’s Story

By Dr. Michael Warner
In Healthcare Business Monthly
Mar 1st, 2020
Comments Off on Capture the Patient’s Story
Status of Chronic Condition/ Disease provides an opportunity for improved documentation. Capturing within the medical record a patient’s story and their experience living with a medical condition or disease can be a struggle. Research in a medical sc...
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