Information should be checked and updated to avoid cloning and up-coding
TUESDAY, May 26, 2015 (HealthDay News) — Caution should be exercised with use of electronic health record (EHR) documentation short cuts, according to a report published in Medical Economics.
The article addresses potential misuse of short cuts with EHRs, including templates and sets of information that can be inserted easily, copying verbatim from one’s own or another provider’s notes.
According to the article, cloning (copy-and-pasting) allows users to select information from one source and paste it elsewhere. However, the information should be updated and verified in order to ensure that information is accurate and billing is correct. Some EHRs auto-populate fields when using templates and others generate documentation by clicking a single checkbox. Physicians must edit appropriately, otherwise the documentation can suggest that the practitioner performed more comprehensive services than were billed (up-coding).
“If you use [shortcut features], be sure to review and update the information to reflect the any changes in the patient’s history or condition — and your work — specific to that day’s visit,” according to the article.
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