Effects of Aligning Residency Note Templates with CMS Evaluation and Management Documentation Requirements

Area of Science:

• Medical Education
• Health Informatics
• Clinical Documentation Improvement

Background:

• Centers for Medicare & Medicaid Services (CMS) revised outpatient and inpatient evaluation and management (E/M) Current Procedural Terminology (CPT) codes in 2021 and 2023.
• These revisions aimed to simplify clinical documentation requirements for healthcare providers.

Purpose of the Study:

• To evaluate the impact of updated inpatient and outpatient note templates on documentation character length and time.
• To assess the effect of aligning note templates with current CMS guidelines within an internal medicine residency program.

Main Methods:

• Internal medicine residency note templates were updated in April 2023 to reflect the latest CMS guidelines.
• A pre-post analysis compared resident documentation (May-August 2022 vs. May-August 2023) for character length and time.
• Resident perceptions of the updated templates were gathered via a survey.

Main Results:

• Notes decreased by a mean of 882 characters post-update (p < 0.0001).
• No significant reduction in mean documentation time was observed after adjusting for note type distribution and resident authorship.
• All 17 surveyed residents reported favorable perceptions of the updated note templates.

Conclusions:

• Updating note templates to align with CMS E/M documentation changes resulted in a significant decrease in documentation length.
• Despite reduced length, overall documentation time did not significantly decrease when accounting for study period variables.
• The updated note templates were positively received by residents, suggesting potential for improved user experience.