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 ...
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 ...
Jun 1st, 2014
Maximize the full potential of EHR tools, but abide by the documentation rules. By Ronda Tews, CPC, CHC, CCS-P Electronic health records (EHRs) are supposed to save providers time and improve the quality and legibility of their documentation. Another hoped-for advantage of EHRs is better patient care. EHRs are not intended to increase the quantity ...
[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 ...
Don’t let cloned documentation sink your coding and compliance efforts. by Joyce Will, RHIT, CPC Although Medicare doesn’t have a national policy on the use of shortcuts (such as templates or copy and paste functions) when physicians and non-physician practitioners document services in an electronic health record (EHR), the subject of “cloned notes” continues to be ...