2 Things to Remember about Using Your EHR Compliantly

Lea Chatham May 14th, 2014

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By Betsy Nicoletti

Learn about OIG EHR recommendationsPhysicians and other healthcare providers can be excused if they feel a sense of irony about the messages they get about their Electronic Health Records (EHRs). First, we ask them to switch their method of record keeping from paper to computerized and then caution them, “But please don’t use them conveniently, by copying from one note to another.” There are constant warnings about cloning. Even the popular press reported on recent Office of Inspector General (OIG) reports about the topic, finding “errors in digitizing” medical records. This leaves clinicians, coders, and managers with questions about how to use their EHRs effectively and compliantly. Two of the many issues highlighted in the recent OIG reports were authorship and copying and pasting from a previous note.

Sign & Date Entries
All entries into the medical record should be dated and signed and the authorship should be crystal clear. “Written by Anonymous” is good for the author of a Victorian novel, but not in the EHR. Medical assistants should sign their portion of the note when entering the reason for the visit. It shouldn’t be confusing to a reader what part of the history was entered by the MA or nurse and what part was entered by the billing provider. If a record is shared between two providers, such as a Physician Assistant and physician each professional should enter and sign their own portion of the note.

Although we all want to be part of the healthcare team, there is no “we” in medical record documentation.Tweet this Kareo story

Use Caution When Copying Notes
Clinicians do want to carry forward history from note to note. Often the medical assistant will enter or review this data, but if a clinician signs off on the note, it is assumed that the clinician also reviewed the data. That is, the billing provider is responsible for what is in note that day. Past medical, family, and social history recorded at a previous visit can be reviewed and updated and incorporated into a current encounter. Diagnostic data is also often summarized and carried forward, making data retrieval easier for the clinician. Coders and clinicians often have differences of opinion about the history of the present illness. Coders tell clinicians not to copy anything into the HPI section of the note from a previous visit and clinicians tell coders it is clinically relevant and a time saver to do so.

I distinguish between a clinical summary that is carried forward from the HPI documented at the current visit. An example of a clinical summary is, “this is 78 year old woman with COPD, lung nodules by CT scan and asthma. She is a past smoker, who quit at age 55 after a bout of pneumonia.” Then, the provider would add the HPI. “Since I saw her six months ago, she reports a worsening of her symptoms and an increase in shortness of breath.” The clinician is happy because the clinical summary is available at each visit, and the coder is happy because the HPI is documented after the statement, “Since I saw her six months ago.”

Medical practices should heed the OIG warnings and recommendations regarding EHRs. Many of the recommendations are easy to implement. Some require only this: remembering that although we use the documentation for billing and coding, the primary purpose of the medical record is healthcare communication.

Adopting the OIG recommendations will protect the integrity of the medical record.Tweet this Kareo story

To learn more about the latest OIG recommendations, join me at my upcoming webinar, Your Medical Billing Software: Coding Pitfalls and Promises.

About the Author
Expert Betsy_Nicoletti_advises how to improve your patient collectionsBetsy Nicoletti is the author of The Field Guide to Physician Coding and the 2007 Physician Auditing Workbook, as well as founder of Codapedia.com. She developed The Accurate Coding System to help doctors get paid for the work they do. She simplifies complex coding rules for practitioners and engages physicians in a positive and respectful way, which encourages attention and accuracy in their coding. Besides doing auditing and compliance work, she is a speaker, writer and consultant in coding education, billing and accounts receivable.

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