Post-webinar resources
Everything from today's E/M coding hour, ready to download. Each tool takes the reasoning you already do and puts it in the note, without making the note longer.
One short form, all seven files.
One to one with Dr. Heather Signorelli, our co-founder. She reads your denial rate, your aging and your payer mix, and tells you what they mean. Free, and nothing to buy at the end.
Why these exist
You weigh the risk, rule out the dangerous cause, decide against a medication because of what the patient already takes. It takes seconds and it is the hardest part of the visit.
What reaches the note is Records reviewed. and Continue current meds. Both are true. Neither one shows the judgment behind them.
Under the current framework, cognitive work that is not visible in the note cannot count toward the complexity of medical decision making.
You do not need longer notes. You need clearer ones.
Five tools, built for the ninety seconds you have.
The same visit, written two ways
Established patient with hypertension, not at goal on Lisinopril. Both versions describe the same encounter and take about the same space. Switch between them.
Hypertension. BP elevated today at 150/90. Add Amlodipine 5mg. Return in 4 weeks.
Accurate, and it still does not say why this plan was chosen.Essential hypertension, currently not at goal (BP 150/90) despite adherence to Lisinopril 10mg.
Reviewed home BP log; consistently elevated in the 140s/90s over the past two weeks.
Added Amlodipine 5mg daily. Discussed risk of hypotension and peripheral edema.
RTC in 4 weeks for BP check and basic metabolic panel.
Case 01 of twelve, from the casebook. Every case also shows what change in the facts would alter the outcome.
The downloads
File 01 is everything in one document. Files 02 to 07 each solve one moment: closing a complex note, reviewing one that came back reduced, building the phrase once so you stop rewriting it. Two are made to print.
File 01 of 07 · Start here
The MDM Note Builder, the twelve-case casebook, the SmartPhrase pack, the MDM or Time card and the hidden-work reference. If you take one thing today, take this one.
Download the 34-page PDFThe toolkit fixes the notes you write from here. A metrics review looks at what your notes already produced. Free, one to one with Dr. Heather Signorelli, our co-founder.
Four steps: status, data, decision and risk, next steps. Write them in your own words and the note explains itself.
Twelve everyday encounters, each written twice: the thin version, the defensible version, and what would change the result.
Five macros to build once in Epic, Cerner or the equivalent. They prompt you for the detail instead of importing generic text.
When to use medical decision making, when to use total time, and the three things a time statement has to include. Index-card size.
The same card on standard office paper, for the clinic printer or a shared workstation.
Six kinds of work that usually go undocumented, from reviewing outside records to deciding not to prescribe, with the wording that makes each one visible.
Inside the toolkit
Every tool runs on the same sequence. Hover a step to see the sentence you write.
Establishes the complexity of the problem you addressed today.
Proves the cognitive work of reviewing or analyzing, beyond a generic “records reviewed”.
Links the management decision to this patient's specific risk.
Demonstrates active management and safety-netting.
The Note Builder turns this into a one-page card. The SmartPhrase pack turns it into macros your EHR fires for you.
Six kinds of hidden work
Hover a card to flip it. All six are in Make the Work Visible, with the MDM element each one feeds.
“Records reviewed.”
“Reviewed Dr. Smith's cardiology note from 10/12; confirmed EF is stable, allowing us to proceed with...”
“Plan: continue current meds.”
“Considered adding [Medication X], but deferred due to risk of interaction with the patient's current [Medication Y]. Will monitor.”
“Referred to ER.”
“Discussed case directly with Dr. Jones (ER attending) regarding the atypical presentation; agreed on direct admission.”
“Gave samples.”
“Patient unable to afford prescribed inhaler (SDOH: economic barrier). Provided samples today to prevent acute exacerbation; social work consult placed.”
“Patient presents with...”
“History of present illness obtained from the patient's daughter, as the patient's dementia precludes a reliable history.”
“Order CT.”
“Ordering CT to clarify the cause of [specific symptom] and evaluate for [clinical concern] given [pertinent finding].”
Your first week
Three changes you can finish this week.
Put two macros from the SmartPhrase pack into your EHR and run them in a test chart until the prompts fire correctly.
Run the before-sign question from the Note Builder on your next five complex notes. It takes seconds and usually finds one missing sentence.
The Note Builder and the decision card. Keep them where you close charts, not in a folder.
The question every note has to answer
If the answer is no, the fix is missing clinical reasoning, not more templated text.
Next step
The RECOVER Diagnostic takes five minutes and tells you which leak is most likely draining your collections, and what to check first.
Run the RECOVER Diagnostic →Coming up next
Wednesday September 30, 5:00 PM EST. The OB global package and the documentation that has to support it, with a toolkit built the same way as this one.
You are downloading
All seven files unlock at the same time.
The file opens as soon as you submit, and a copy goes to your inbox.
Your file opened in a new tab. The other six are below.
