2026 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2025-Electronic Medical Records: The Good, The Bad, and The Ugly

Pdf Summary

This presentation by Kristin Vaughn addresses the critical aspects of Electronic Medical Records (EMRs), focusing on safe and effective documentation practices, challenges, and regulatory considerations. <br /><br />Key points include the appropriate use of templates, emphasizing that templates must reflect medical necessity and be individualized for each patient encounter. The chief complaint should guide the history of present illness (HPI), which should then align with the assessment and plan of care. Special attention is required for telehealth physical exam templates, limiting documentation to what can be observed without physical contact, especially in audio-only visits. Outdated telehealth templates should be updated regularly.<br /><br />The issue of "cloned" documentation—copying and pasting previous notes—is a significant problem leading to inaccurate, redundant records that can confuse patient care and risk compliance. Practices are urged to develop policies to limit cloning, focus on unique, encounter-specific notes, and avoid over-reliance on copy-paste functionality. Auditors now scrutinize the quality of notes and may disallow reimbursement for cloned visits.<br /><br />Voice recognition dictation tools require user training to ensure accuracy, as incomplete or incorrect notes remain the author’s legal responsibility. Regarding AI-generated documentation, providers must clearly indicate its use, thoroughly review and finalize all AI-generated notes, and maintain medical necessity focus. Healthcare providers should treat AI vendors as business associates and conduct appropriate HIPAA risk analyses.<br /><br />The CMS Electronic Medical Record Fact Sheet underscores EHR benefits—including streamlined coordination and reduced duplication—but also outlines challenges such as privacy, author identification, data alteration tracking, cloning, and potential upcoding due to automated prompts or templates. EHR systems should ensure secure access, detailed audit trails, and proper documentation of modifications. Providers carry a legal duty to document services accurately.<br /><br />Overall, the presentation stresses diligent, patient-specific documentation, cautious use of technology, and adherence to regulatory standards to maintain compliance and quality in electronic medical records.

Asset Subtitle

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

Keywords

Electronic Medical Records

EMR documentation

templates in EMR

telehealth documentation

cloned documentation

voice recognition dictation

AI-generated notes

HIPAA compliance

CMS EHR guidelines

medical necessity documentation