Arm against fraud risks EHRs pose, and develop policies to reinforce compliance. Electronic health records (EHRs) make documentation more legible, but they also make it easier to inflate content. Evaluation and management (E/M) documentation is especially prone to EHR shortcomings because of the repetitive nature of these services. Let’s consider the risks and resolutions. Authenticate ...
A little preventive maintenance will ensure your physicians are capturing accurate documentation. Electronic health records (EHRs) can make documentation and billing processes easier, but some EHR features can leave your practice vulnerable in ways the vendor may not have explained. In the time it takes to drink a cup of coffee, you can perform some ...
by Joyce Will, RHIT, CPC Many electronic health record (EHR) systems allow providers to set up default or pre-populated templates. Others allow a provider to “reuse,” or copy/paste, a previous note (a process known as “cloning”). One downside of such tools is the potential for outdated (or even incorrect) information to be carried over, thereby ...
Mar 1st, 2015
Don’t forget medical record integrity as you strive to improve productivity. By Kellie S. Hall, CPC, CPCO, CCS-P Electronic health records (EHRs) offer providers many benefits, but using the technology in compliance with government standards takes a bit of know-how. One such compliance risk EHRs facilitate is called “cloning.” Recognizing cloning and discouraging its use ...
[On the Cover] Ensure clinical documentation integrity in your electronic health records. By Michael Stearns, MD, CPC, CFPC There are advantages and disadvantages associated with the use of imported text in electronic healthcare records (EHRs). Let’s explore efficient documentation practices that support the integrity of the clinical record and prevent exposure to the potential risks ...