Common EHR Mistakes Urologists Should Be Aware of
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Unlike paper records, electronic health records or EHRs make it easier for urologists to document various urology concerns (for example, BPH, Renal Colic, Prostate) and procedures (for example, urodynamic studies, prostate biopsies). The pre-loaded urology-specific templates allow physicians to simply add case-specific information and complete documentation quickly. This rich set of templates is suitable for urology practices of any size. Though this system makes your documentation tasks easier, mistakes can creep in. Let’s move on to those mistakes and explore why urology transcription is still relevant in this digital age. The common mistakes found while using EHR for urology practices are as follows. Copying Chief Complaint and HPI
In order to save time, physicians used to copy the chief complaint and the History of Present Illness (HPI) from the previous encounter of a particular patient and paste those details in the documentation templates for that patient’s current visit. This is quite confusing from the clinical standpoint and the details may be incorrect. If such an error occurs in the EHR documentation, it is very difficult to track that error and it may eventually lead to more serious problems. It is therefore always advisable to create new chief complaint and HPI for each visit and retain the older HPI and chief complaint where it belongs. Copying ROS and PFSH
There is a practice of copying review of systems (ROS) and past, family and/or social history (PFSH) from the last visit, if the documentation is identical with just a few changes.
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This is also not a good practice as you are required to document for the work done for that day, not what was done during the last visit. It is better to add a new template indicating any changes to previous ROS and PFSH in the current visit. Not Documenting the Reason for Ordering a Test
Though most templates allow you to document that you have ordered a test, it is not easy to document the reason why the test is ordered using templates. As medical necessity is gaining more and more importance, it is very important to document the reason for ordering the test. In addition to that, the correct diagnosis is required for each test. If you are giving incorrect reasons, it will not only affect patient care but also lead to claim denials and subsequent appeals. You should ensure that the reason for the test ordered is documented next to the test or in another reliable location. Certain templates allow you to create prompts next to the tests that are ordered frequently with descriptions capturing the reason for each test. Wrong Diagnosis
Even though this problem has actually improved with electronic documentation for many encounters, it is still possible to see the same diagnosis for a problem addressed during the last visit on templates without updating to the diagnosis for the problem being addressed that day. Your EHR should capture each diagnosis accurately. In addition to that, you should report the symptoms that are related to the disease, or remove those symptoms that have resolved during the treatment from the active problem list so that they are not reported on your claim.
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Improper MDM Documentation
Certain EHR templates won’t help you clearly document your assessment and/or plan for a particular patient visit. The common problems found in Medical Decision Making (MDM) documentation are:
Not able to clearly state that you have reviewed the images versus reading the radiology report
Notes do not clearly indicate whether the problem addressed was new during the present visit or was seen earlier
Required data missing on the encounter note
No relation between the problem and current treatment or diagnostic pathway
No clear risk notation from disease process or treatment pathway
These faults will result in increased explanation, additional chart review and even denials. Lack of Consistency
Sometimes, the data entered into the EHR may not meet the requirements of all users within the same practice. Some may require compact data and others may require more detailed descriptions. The placement of critical data in different parts of the record is very important. EHR templates should be consistent to collect relevant data and package in a form that is easily accessible to others. This will enhance the communication between peers in a facility and improve the quality of care.
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Relevance of a Combined Approach – EHR and Transcription
These pitfalls with electronic documentation hint at the fact that it may not be advisable to rely upon EHR completely. Human intervention is required to produce accurate and comprehensive medical records. Here is the importance of a combined approach involving EHR and transcription, especially when dictation and medical transcription has always been a preferred method of documentation. Though traditional transcription lost its importance with EHR templates that allows easier documentation, the service of transcriptionists is still relevant as medical language specialists to ensure the accuracy of data within the EHR. In the combined approach of EHR and transcription, the transcriptionists review and edit the data instead of transcribing in a complete narrative format and enter the data into appropriate EHR fields. In this way, urologists can ensure that the documentation of chief complaint, HPI, ROS, PFSH, MDM and reasons for test ordered are accurately documented. They can also make sure that the documentation is consistent.
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