Electronic Medical Record Documentation Pointers

Although using an electronic health records makes patient charting more inclusive and legible, and less time-consuming, don’t let the ease of point-and-click documentation sway your coding practices. Avoid these pitfalls:

  • Patient care driven by templates and payments,
  • Inaccurate charting via point-and-click mentality,
  • Documentation cloning (wording documentation the same or similarly throughout medical record entries for a patient or across patients),
  • Use of addendums for additional payment rather than clarification of patient care,
  • Copy and paste capabilities,
  • Use of default or prepopulated documentation,
  • Documenting negative symptoms but not positive ones,
  • Failure to review available or historical information, and
  • Signing notes electronically prior to final review.

These practices can flag you for an audit or leave you in hot water in the event of an audit. To evaluate your practice’s coding patterns and risk for audits, contact TMA Practice Consulting at (800) 523-8776 or practice.consulting@texmed.org.

Published Feb. 8, 2010


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