EMR Documentation The Risks and Rewards. Agenda
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1 EMR Documentation The Risks and Rewards Shellie Sulzberger, LPN, CPC Coding & Compliance Initiatives, Inc. Agenda Outline potential compliance issues related to documentation with an electronic medical record (i.e. items pulling forward, discrepancies in the HPI and ROS, several active problems pulling forward not pertinent to the visit) Discuss the risks of an EMR automatically coding for you 1
2 Potential Benefits of EMR Improved documentation of the patient encounter to assist in reduction of medication errors through computerized physician order entry (CPOE) Improved tracking of ancillary and diagnostic tests combined Improved documentation of the service actually provided when the EMR is used correctly Legible notes Potential Benefits of EMR Better communication between the patient and physician and other providers Accessible from remote sites Improved efficiency in regards to staff looking for lost medical records Allows you to track outcomes for quality care initiatives More accurate billing and more efficient charge entry 2
3 Risks Associated with EMR There can be cloning notes from previous appointments Learning curve for the providers Identical documentation Loss of human touch and individuality Difficult to determine what the provider is recommending for the patient Documentation is not always patient and chief complaint specific Difficult to determine who performed specific elements Risks Associated with EMR The EMR can drive a provider to include documentation that is not applicable for the severity of the presenting problem. A 25 year old patient who comes in for a cough has documentation to support a complete review of systems (i.e. 10 or 12 point) and a family history because the EMR can automatically imports such text from the previous visit. Medicare and other payors will look to see whether the severity of the patient s problem matches the documentation, and if it doesn t it s a red flag. 3
4 Risks Associated with EMR Documentation templates default to multisystem reviews, exams, past problems that are no longer active, but still indicate Active Problems, etc. whether you do them or not. Usually it takes too much time and trouble to edit them out so the providers leave the information in the note for that date of service. Although excellent features of EMR systems, default settings and documentation templates can be dangerous Patient presented with knee pain. A complete review of systems was documented including breasts and ob/gyn this was a male patient and breast and ob/gyn issues would be unrelated and not relevant for knee pain. 4
5 A specialty provider (cardiologist) saw a patient for heart issues. The provider saw the patient multiple times and on the initial visit the history and review of systems indicated the patient was coughing up blood and also their weight was down 10 pounds. Every note after the initial had the exact same review of systems, however, the history outlined the weight was up by xx pounds, etc. I was asked to review several notes for a Work Comp case because the provider had a very high percentage of I reviewed 5 patients and looked at 3 4 dates of service for each patient. Only a few items changed with each review and there were documentation errors due to pulling the information forward, such as visit #1 when it was the third visit. 5
6 A gastrointestinal provider had a complete physical including genitourinary when evaluating the patient for a colonoscopy. When I asked the provider about it, the provider said oh my gosh, I had no idea that was in there. I was told if the patient s exam is completely normal, I can click the button and then if I need to make any changes about abnormalities or more detail I can just add it in. I was reviewing documentation in a surgeons office and noticed several instances where the ROS was positive for several items that were not addressed (i.e. short of breath, heart palpitations, chest pain, depression, etc.) The surgeon told me that he never reviews that information it is a bubble sheet that is completed and scanned into the system. He also said he does not base his coding on these ROS. 6
7 Reduce Risk Obtain an independent assessment of your EMR documentation Evaluate the documentation in comparison to the presenting problem Ask the auditor to look at the templates you have Is the template prompting for more information than required for the presenting problem Reduce Risk Ask for a list of everything that automatically pulls forward and a list of everything that can pull forward Print out the note Can you tell who did what work? 7
8 Coding Module Is your coding module turned on? Should we turn it on or leave it off? Contact Info. For Questions Feel free to contact us with any questions related to EMR documentation risks. You can reach us at: or
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