2024 Gastroenterology Reimbursement and Coding Update | November 2023-15 - Electronic Medical Records Good Bad and Ugly

15 - Electronic Medical Records Good Bad and Ugly_Vaughn

Pdf Summary

This document discusses the use of Electronic Medical Records (EMRs) and highlights some of the positive aspects as well as the potential issues that may arise. The presenter emphasizes the importance of safe and effective use of templates in EMRs, ensuring that each note is specific to the patient's chief complaint and that the information flows logically from the Chief Complaint to the History of Present Illness (HPI) and the assessment and plan of care. Cloning, which involves copying and pasting information from previous notes, is cautioned against due to the risk of redundancy and inaccurate information.<br /><br />The document also mentions the use of dictation and voice recognition software, such as Dragon, for documenting patient encounters. Providers are advised to ensure that the dictated notes make sense and to complete any missing information before finalizing the document.<br /><br />Furthermore, the document highlights a fact sheet by CMS on EMRs, which praises the benefits of EMRs in terms of reducing paperwork, eliminating duplicate tests, and facilitating billing. However, it also acknowledges the concerns of physicians regarding issues such as interoperability, documentation overload, and untested billing systems. Specific challenges like security and privacy issues, author identification, altering entry dates, cloning, upcoding, and coding modifiers are mentioned.<br /><br />Overall, the document provides an overview of EMRs and emphasizes the importance of using them effectively and complying with documentation standards to ensure accurate and quality patient care.

Keywords

Electronic Medical Records

EMRs

Templates in EMRs

Safe use of templates

Chief Complaint

History of Present Illness

Assessment and plan of care

Cloning in EMRs

Dictation software

Voice recognition software