2 minute read
Legal Update II
Elizabeth Hogue, Esq.
Responding to regular audits has become an ongoing burden for many providers. Providers have repeatedly been urged to “paint a picture” of patients in clinical documentation in order to help achieve positive audit results. “Painting a picture” of the patient, however, may have become more difficult as the use of electronic health records has increased.
Audits, audits, and more audits of patient records! Responding to regular audits has become an ongoing burden for many providers. Providers have repeatedly been urged to “paint a picture” of patients in clinical documentation in order to help achieve positive audit results. “Painting a picture” of the patient, however, may have become more difficult as the use of electronic health records (EHRs) has increased. That is, it’s difficult to adequately describe patients’ conditions when there are so many boxes to check and blanks to fill in. In addition, when it comes to narrative descriptions of patients’ conditions, it is extremely tempting to “copy and paste,” “cut and paste,” and/or “copy forward” previous documentation in the EHR. The copy and paste feature allows users to use the content of another entry and to select information from an original or previous source to reproduce in another location. The copy forward capability replicates all or some information from a previous note to a current note, while the cut and paste feature removes documentation from the original location and places it in another location. In addition to the obvious potential problems for quality of care related to the use of these functions, auditors are understandably continued on page 36
Elizabeth Hogue, Esquire, is an attorney who represents health care providers. She has published 11 books, hundreds of articles, and has spoken at conferences all over the country. LEAD THE DELIVERY OF WORLD-CLASS CARE
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