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My general template is: Age, sex, relevant RF presented (if it's by ambulance I'll add it, otherwise I leave mode of arrival out) with SXS and laterality and found to have xyz with THIS management on such and such date.

For example: 50 yo M with CAD, PAD s/p prior left BKA (2/2020) and uncontrolled DM presented via ambulance with severe, crushing left chest pain and found to have new 90% blockage of LAD s/p revasc with stent placement on 02/11/22. Pt asymptomatic today and stable/doing well, etc.

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That's why my MDM specifically references important lab/imaging results. If somebody has chest pain, it's much more useful for me to say "d-dimer (0.61) less than age adjusted cutoff, troponin within normal limits and stable on 1 hour repeat" than it is to pull in a whole page of labs including the CBC/diff, electrolytes, etc.

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What’s ridiculous is they weren’t even referring to mentioning it in the MDM. Their understanding of it was if I mention leukocytosis in my MDM but don’t physically have their CBC the claim can still be made I didn’t review the lab.

“Relevant labs are helpful, and most EMR has horribly user unfriendly MAR so the best way to know what meds were ordered on a particular day is by the notes from that day. Since the software can’t tell what’s relevant, it spits everything into the note.”