ICD10monitor January 30, 2023
Erica E. Remer, MD, CCDS

Make your documentation tell a story that makes sense to the reader.

I have been talking about improving the electronic medical record and making it more end-user-friendly. Today, I am going to grouse about documentation in general.

My husband, who is a radiologist, and I were commiserating at how awful and uninformative provider documentation has become since we started practicing medicine in the 1980s. In the handwritten days, the story was better; it was just often illegible. But people didn’t waste copious chart real estate on useless rehashing of details which weren’t helpful even the first time they were introduced into the record.

I am going to share with you some of my biggest pet peeves and tell providers how...

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