Pediatric Coding Alert

Keep sufficient paperwork on hand to back up EHR. Transitioning to the world of electronic health records (EHRs) can make your coding easier on many levels, but don't take it for granted. Physicians often fall short in their review of systems (ROS) documentation whether you use paper charts or rely on EHRs, but you can help correct the deficiency. Consider this situation and decide how you would handle it before reading on for our experts' advice. Scenario: The pediatric practice uses EHRs, and one physician has a sheet listing any concerns or problems that the patient fills out prior to her visit. The physician uses the sheet as his review of systems (ROS) for chart note documentation. He lists anything the patient marks as positive and then states "all others negative." He discards the original form the patient completes. Concern: What happens if the chart is audited -- would the [...]