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.
Medical Billing Blog
When Documenting in the EMR - Medical Necessity Remains Central
Posted by
Scott Shatzman on Fri, Mar, 31, 2017 @ 09:03 AM
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