Wiki Ehr/emr

[KMCFADYEN]

Is it necessary for the EHR to contain all documentation for what we are billing? We have a physician who keeps a paper chart as well that contains additional info not in the EMR. We have tried to get him to upload this info but he seems to think it is not a problem if it is in the patient's "paper chart". We are trying to avoid any future issues but cannot seem to find anything in writing to back this up.

 

[mitchellde]

If you profess to be an all electronic system then yes all info must be in the electronic chart.

 

[cluke]

Depending on your EHR/EMR system, you may want to have the provider (or ancillary staff) scan the paper portion of his documentation to attach to the electronic record for that date of service. Really, he needs to pick one format, but....easier said than done.

I am currently working as an auditor for a payer and we will audit both pieces of documentation to combine as a whole for auditing purposes.

Good luck!