Mar 30th, 2017
Since electronic medical records (EMR) have become prevalent, there has been concern whether documentation in the patient record accurately reflects medical necessity and the services provided. When I started working in the healthcare setting, we always told providers, “Not documented, not done.” Now, when I review a chart note, the question I have to ask ...
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 ...
In Audit
Sep 15th, 2015
by John Verhovshek, MA, CPC Electronic medical records have simplified documentation and record tracking. In some cases, the electronic record allows the physician to bring forward, or to “cut-and paste,” previous patient information. Although this may save time, progress notes are critical to support medical necessity. For example, if an inpatient’s improvement and/or regression is not ...
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 One downside of such tools is the potential for outdated (or even incorrect) information to be carried over, thereby ...
In Audit
Jul 1st, 2014
CMS allows providers to use documentation templates, but the resulting encounter note must be specific to the patient, date of service, and service(s) rendered. If you use (or plan to use) documentation templates in your practice, consider these basic compliance guidelines, as provided by WPS Medicare: Either the ancillary staff or the patient may complete ...