Your Top EHR Documentation Questions Answered

Lea Chatham October 29th, 2013

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As a follow up to our recent webinar, EHR Documentation: Truth or Consequences, speaker Barbara Drury and Kareo have answered the many questions posed by participants. Here are a few of the top questions you asked:

Q: I am new to EHRs. What is HIE?
A: HIE is health information exchange. It can be used to refer to the direct exchange of patient information from one provider to another, or, more commonly, the use of a third-party to exchange information. There are state-based and regional programs that promote the exchange of health information through their networks to improve coordination of care and access to patient’s medical records. There are also private HIE’s, typically these are sponsored by a hospital in order to further engage the hospital’s base of physicians. For more information, visit www.healthit.gov

Q: We are a physical therapy clinic that is planning to add an EMR in January. We are a manual therapy clinic meaning the physical therapists are HANDS ON with the patient therefore patient notes are done afterwards. Are you saying that the time of when the note is done matters?
A: There are no specific rules about the timing on creating or signing notes. However, to protect yourself in the event of a lawsuit or audit, I do recommend doing it sooner rather than later. I suggest within two to three days to ensure the notes are accurate and timely. This is also important as it relates to your revenue cycle. Complete documentation is needed to finish a claim and submit it. You should be submitting claims at least every two to three days, and ideally, daily. In addition, there may be clinically relevant instructions or educational resources that need to be documented before the patient leaves the building, such as vitals, exercise regime, equipment to be ordered, etc. Efficiency may guide you as to which steps should be documented before the patient leaves and which could be documented later in the day.

Q: Wouldn’t information provided thus far indicate that due to flaws or gaps in EHR, a paper backup copy is still needed?
A: I would not suggest creating any paper copies simply as a CYA, “just in case” you get sued. That would be terribly burdensome and not very useful as there are so many output formats from the EHRs you would likely still have an incomplete picture of the patient. I would suggest strongly that there be a disaster plan about how to document when the EHR is not available for new documentation. This disaster plan would include a paper form that mirrors the typical flow of the EHR’s input screens and describes how that paper form, used in case of no access, would later be entered into the EHR and scanned as confirming documentation. Keep in mind, that a scan has no discreet data for any calculations or trending. Some practices that have relatively static and reliable patient flow may set-aside a Friday afternoon to print “next week’s” schedule and the latest summary sheet for the patients who are scheduled next week. If the EHR is always available that next week, then all the material must be shredded. In case of no access to the patient’s past visits, the clinician will need to proceed as though the patient had never been seen, asking all history questions, medications, allergies, etc. and it would be written on that paper disaster form and entered later.

If you missed this great webinar, you can view the recorded event or check out the slides. And check our next event on ICD-10, which is November 13.

About the Speaker

Register now for discussion about EHR Documentation with Barbara Drury

Barbara Drury, BA, FHIMSS, is President of Pricare Inc., an independent health information technology consulting firm founded in 1982. She frequently lectures and writes about the impact of office-based computer systems and electronic medical record systems for entities such as medical societies, healthcare organizations, and others. Ms. Drury is an appointee to the ONC’s Technical Expert Panel on Unintended Consequences of HIT Adoption. She has achieved Fellow Status with the Healthcare Information and Management Systems Society (HIMSS) and currently serves on the HIMSS Public Policy Committee. Ms. Drury is also a frequent speaker at the HIMSS Annual Conference and is the recipient of the December 2004 and the April 2009 Spirit of HIMSS award.

 

 

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