Since electronic medical records (EMR) have become prevalent, there has been concern whether documentation in the patient record accurately reflects medical necessity and the services provided. When I started working in the healthcare setting, we always told providers, “Not documented, not done.” Now, when I review a chart note, the question I have to ask myself is, “There is documentation, but was it done, today?” With the ability to import previously gathered information into the current note with just a few clicks, it’s possible that the information wasn’t reviewed at that specific encounter.
A particular area of concern is the use of templates in the EMR. With providers’ patient volume requirements increasing, templates have become a timesaving feature used by many providers. But, this tool can become a trap leading to a poorly documented note. Educating providers to thoroughly review with the patient information contained in the patient’s template, at each use, is paramount. The provider should clearly document that information obtained at a previous visit was reviewed with the patient at the present encounter, and note changes, as appropriate. This should alleviate concerns that the provider is misusing the features the EMR offers.
Information pulled from one patient encounter to the next often contains past medical, family, and social history along with review of systems. Sometimes, the templated information will contain data that is in direct conflict with the patient’s presenting problem. Without the provider’s review of the automatically populated information, the accuracy of the note could possibly be compromised, and—most importantly—patient care could be negatively affected.
Because medical necessity is the driving force behind the billable level of service, provided templates can be cumbersome. Often, templates include every possible exam element. The provider is faced with the task of reviewing and amending each element and removing the inappropriate ones. Often, much of an exam is not relevant to the patient’s chief complaint. Removing and or modifying the templated information for each encounter may take more of a provider’s time than if he or she had not used a template.
Another concern with the electronic medical record is that the provider can easily pull in previous diagnoses. There are times when the patient’s chronic conditions are relevant to a particular date of service, and there are times when they are not. If the provider uses the coding feature offered by some electronic systems and makes a wrong click of the mouse, the provider can falsely inflate the level of service.
Practices need to review whether the use of features offered by their practice management system can be beneficial to the provider—and if so, how extensive the use should be. Those of us in healthcare support positions play an important part in educating our providers on all of the tools that are at their disposal, and how to best use them.