2025 Gastroenterology Reimbursement and Coding Update (On-demand)| November 2024-Electronic Medical Records- The Good, The Bad, and The Ugly

Video Transcription

Video Summary

The video discusses the "good, bad, and ugly" aspects of electronic medical records (EMR), focusing on documentation practices. Key issues include the use of templates, cloning, and dictation with voice recognition software. It highlights the responsibility of providers to ensure accurate documentation, stressing that each patient encounter should be unique and specific to the medical necessity. The talk also addresses the challenges of telehealth documentation, emphasizing correct templates for different encounter types. The speaker warns against cloned documentation, suggesting customization and careful review of notes to avoid inaccuracies. Cloning, altering dates, and upcoding in EMRs pose challenges, with government bodies paying closer attention to these practices. Providers are urged to ensure that security measures are in place to protect patient information and comply with documentation standards. The video underscores the importance of accuracy and responsibility in the use of EMRs, with a focus on quality over quantity in medical records.

Asset Subtitle

Kristin Vaughn, CPC, QMC, QMGC, CPMA, ICDCT-CM

Keywords

electronic medical records

documentation practices

telehealth challenges

cloned documentation

patient information security