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. 

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