Electronic Medical Records Systems: Documentation software, discharge instructions, and electronic prescriptions.

Co-morbid Conditions: Include all complicating chronic medical conditions in your diagnosis, whether related to the chief complaint or not. Some co-morbid conditions not only support a higher E&M level, but will also help support certain DRG's.	Re-evaluations: Be sure to note responses to therapeutic interventions such as breathing treatments. This supports an optimal E&M value.
Febrile: When a patient presents with a febrile condition, especially a child, it is important include this in the final diagnostic listing.	Pulse Ox: Be sure to make a not of what the measured number represents. i.e. hypoxia. Simply writing the numerical value down isn't sufficient.
EKG: Simply noting a normal finding is not sufficient. The rhythm and rate must be noted, in addition to the presence or lack of ectopy.	Lack of Medical History: If unable to obtain certain medical history or ROS data, be sure to note why the information was unavailable. Simply stating unable to obtain may not prove to be sufficient to support the E&M criteria.
Splints: If performed by the physician, be sure to document "done by physician".	ABG: Normally the interpretation of an ABG isn't considered a separate charge from the E&M level. However, if the physician draws the ABG, then document "ABG drawn by physician".