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Best Practices for E/M Clinical Documentation
In collaboration with the Electronic Health Record Association (EHRA), ACP has developed a set of resources to help physicians adapt to CMS’ 2021 evaluation and management (E/M) code changes and accompanying clinical documentation requirements. Below are tools that can help you determine how to make sure that you have included only those necessary elements in your clinical notes, while avoiding “note bloat” and other burdensome documentation practices.
Learn more about ACP and EHRA’s collaboration from EHRA's blog post.
- 2021 E/M Documentation Guidance, Interpretations, and Questions: Learn more about the changes that were made to E/M documentation guidance for 2021 and questions that remain for physicians and EHR vendors.
- Five Recommendations for EHR Vendors: Learn more about what you may need to consider and discuss with your EHR vendor.
- Primary Care Do’s and Don’ts for Clinical Documentation: A guide for general internal medicine physicians about what to focus on, reconsider, or drop from your notes.
- Medical Specialty Do’s and Don’ts for Clinical Documentation: A guide for subspecialist physicians about what to focus on, reconsider, or drop from your notes.