Effects of Aligning Residency Note Templates with CMS Evaluation and Management Documentation Requirements
The internal medicine residency inpatient and outpatient note templates were updated to align with the most recent CMS E/M documentation requirement changes. These note template changes were associated with a meaningful decrease in documentation length but no overall significant reduction in mean documentation time when adjusted for differing percentages of note types in the pre- and postperoids and multiple notes written by the same author. The interns perceived the note template changes positively.
Authors
- Ajay Dharod (ORCID: https://orcid.org/0000-0002-8033-9009)
- Ted Xiao
- Adam Moses (ORCID: https://orcid.org/0000-0003-2782-5080)
- William C. Lippert (ORCID: https://orcid.org/0000-0002-7684-7553)
- Joseph Rigdon (ORCID: https://orcid.org/0000-0001-6265-0752)
- Lauren Witek (ORCID: https://orcid.org/0000-0001-9604-0629)
- Matthew Anderson (ORCID: https://orcid.org/0000-0002-9092-2580)
- Joseph A. Cristiano (ORCID: https://orcid.org/0000-0003-1388-5867)
- Sneha Chebrolu (ORCID: https://orcid.org/0009-0001-3135-793X)
- Corey Obermiller (ORCID: https://orcid.org/0009-0002-6948-0893)
- Sarah Stern
Institutions
- Atrium Health Wake Forest Baptist (US)
- Wake Forest University (US)
Publication Details
- Journal
- Applied Clinical Informatics
- Published
- 2024-11-21
- DOI
- https://doi.org/10.1055/a-2480-4725
- Citations
- 1
- Primary Topic
- Clinical practice guidelines implementation
- Type
- article
- Field-Weighted Citation Impact
- 0.54
Funders
- National Center for Advancing Translational Sciences