5 EHR Shortcuts That Can Put You at Risk

The use of electronic health records (EHRs) is steadily increasing due to incentives and the promise of a more efficient system. High-level evaluation and management (E/M) services are also increasing.

While these claims might be substantiated by documentation within the EHRs, it doesn’t mean that the documentation is correct or valid.

The ability to use shortcuts for faster documentation, a major appeal of EHRs, can also be bad for your organization. Understanding potential problem areas is the first step to improving E/M documentation. Knowing what your practice will have to prove if audited can help you to mitigate auditing risks.

1. Chief Complaint and HPI: The first thing an auditor looks for is a documented chief complaint.

2. ROS and PFSH Must Be Updated at Each Visit: Documentation guidelines explain that recording the HPI is the physician’s job only; auditors need to ensure the physician documents this portion of the record.

3. Time-Saving Features Can Put You At Risk: The crux of the problem is that the same time-saving features that attract physicians to use EHRs, such as copying and pasting or pulling forward documentation and templates, can also put practices at risk for failing an audit.

4. When Using Templates, Verify the Exam: Templates may also result in documentation errors if exam items are pulled forward that aren’t actually performed, or if the physician doesn’t change a result that may have been positive at a previous visit, but is negative for the current visit.

5. Don’t Overlook Dx Selection: Auditors must look out for assessments populated from problem lists. The history and exam must support each diagnosis, showing that it truly was assessed at that particular visit.

For more EHR Shortcuts that can put your organization at risk, and how to customize EHRs to overcome shortcomings, download our free eBrief, "Be On the Lookout for Misused EHR Documentation Shortcuts", by clicking the button below: