Health Information Compliance Alert

Published on Mon Aug 08, 2022 PDF

Question: We’ve heard many warnings about the dangers of using EHR templates, but we aren’t sure why they’re bad. What’s wrong with them?

Washington Subscriber

Answer: Templates in electronic health records (EHRs) may help save time, but they can also create issues for some practices. Many EHR templates were designed in part to assist providers in efficiently documenting the medical record. However, some of the templates do not appear to be correlated with a providers’ clinical intuition and tend to hinder productivity.

Pre-built templates contain mandatory fields of text that should be deleted if the provider is adding their own information about the patient’s chief complaint, symptoms, or histories. This can be an issue with the free text entry option on the EHR.

EHR errors were said to be more common during the shift to the 2021 E/M Office and Outpatient Guidelines, which are focused on medical decision making. Updating the EHR templates for E/M visits to suit these guidelines is difficult since fulfilling the requirements for E/M visits is a more clinically intuitive process for providers. Typically, one or two education sessions and periodic coding reviews help solidify providers’ comprehension of the guidelines and facilitate implementation to their documentation.

Tip: If you find contradictions in the documentation that may be due to the EHR template and the provider’s free text entry, you can query the provider to ensure the information is accurate. This extra step to correct any incorrect information could help the practice avoid a denial or an audit.