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DUKE UNIVERSITY HOSPITAL DOCTORS ORDERS ED CLINICAL EVALUATION UNIT ABDOMINAL PAINDATETIMEDOCTORS ORDERSEDUCNURSE[ ] Assign to CEU for Observation of ABDOMINAL PAIN CONSULTS: [ ] TREATMENTS: [ ] D50.45
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Evaluation and management (E/M) refers to the process of assessing a patient's condition and providing appropriate care.
Healthcare providers such as doctors, nurse practitioners, and physician assistants are required to document and bill for E/M services.
E/M documentation includes the patient's history, physical exam findings, medical decision-making, and time spent providing care.
The purpose of E/M is to accurately assess and treat patients, as well as to ensure proper billing and reimbursement for healthcare services.
E/M documentation should include details about the patient's chief complaint, history of present illness, review of systems, and any relevant medical tests or procedures.
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