Know What an EHR Says About Your Doctor
Documentation tells a story; make sure the main character is the patient, not the physician.
By Leonta Julien-Williams, CPC, RHIT, CCS
The electronic health record (EHR) has made it easier for patients to access and monitor their health information. I’m sure you’re aware of the type of information found in a patient’s EHR—from basic demographics and current medications, to diagnoses and treatment history. But what does a patient’s EHR say about his or her physician?
Physicians should be aware their documentation tells a story about them just as much as it does their patients. See if your physicians can be “summed up” by one of the following descriptions. If so, now is the time to make them aware of their role in the EHR.
Spelling errors seem more apparent when seen on a computer monitor versus a handwritten note. Imagine reading five consecutive progress notes from five different dates of service and identifying the exact same incorrect spelling of a word or words on each note. This is apt to prompt questions, such as:
- Did the physician really complete the progress note for that specific date of service?
- Did he or she really see the patient on that specific date of service?
These are just a couple questions the Office of Inspector General may ask during an audit.
Using “he” or “she,” or “him” or “her,” interchangeably to describe a patient makes it seem as if the physician does not know the patient. Have you ever read through a record and noticed Mrs. Jane Doe was referred to as “him,” or Mr. John Doe was referred to as “she?” As a patient, I would really be annoyed if I were referred to as “him.” I would like to think my physician knows me pretty well.
Pill Pusher, MD
Some EHRs have the capability to automatically insert a medication refill into the note at the appropriate time. The problem with automatic refills is the lack of documentation from the chief complaint to the assessment, supporting the need for that medication (whether it is a new prescription or a refill). Physicians should also be careful with the way they document a prescription. For instance, an auditor will see red flags if a patient presents with no complaint of pain, a pain scale showing 0/10, and no pain diagnosis for that encounter, but there are prescriptions on that date of service for percocet and hydrocodone.
Coders inherently pay very close attention to documentation, so they notice things such as contradictory information in an EHR. For example: A physician documents on a single date of service, “PMH: Allergic to penicillin” and “HPI: Mrs. Doe has no prior history of allergies.” From the opening remarks (chief complaint) to the history of present illness, review of systems, physical exam, and assessment, the information doesn’t jibe.
The EHR should reflect information about the patient. You should not read an encounter note and immediately recognize which political party the physician is affiliated with. Advise your physician to refrain from documentation such as “patient will get insurance coverage when President ______ allows her to” or “patient would benefit from stem cell research, but our current president does not agree.” This type of documentation is inappropriate. The patient’s EHR is not the platform to express personal opinions. There are medical boards and other resources available for this type of conversation.
The EHR may tell as much about the physician as it does the patient. Don’t allow your physician to fall into any of the categories above. The EHR is a legal document. In an audit or a lawsuit, documentation should be your best defense, not evidence to be held against you. Patients deserve and expect the information in their record to be correct and useful.
Leonta Julien-Williams, CPC, RHIT, CCS, has worked in the healthcare industry for the past 10 years. She has worked as a coder, auditor, and educator. She is a member of the Greater Atlanta, Ga. chapter of AAPC.