Page 12 - Part 2 Navigating Electronic Media in a Healthcare Setting

SVMIC Navigating Electronic Media in a Healthcare Setting

payer and appear to be cloned, this may raise red flags about
whether the actual care was provided to support the level of

coding billed.

If notes are left in an unlocked state on the EHR, potential risks

exist because providers are not aware of later modifications by

staff, and subsequent providers may base treatment decisions on
incomplete information. In the event of a lawsuit, modifications

made after the initial visit note may appear self-serving and create

hurdles with defensibility. Submission of billing prior to the
signature and locking of notes is fraudulent.

Medication Safety

Patient allergies should be verified at each visit or a notation made
of no allergies. If an allergy is discovered during the course of care,

the date of the discovery should be documented in the body of the
notes. Do not rely solely upon dropdown boxes to make changes

to the patient’s medication reactions as some EHR systems post-
populate the record changing the earlier entries, which gives the

appearance that the patient was always allergic to the

medications. Documenting the reaction to the medication in the
body of the record on the date it is discovered protects the

provider from this potential glitch.

If using dropdown boxes from which to select medications and or

dosages, use care to verify that the correct medication and the

correct doses have been selected before entering information into
the e-Prescribing system. Ideally, the ordering provider should

enter the original medication order in the EHR. However, if the

practice allows licensed professionals to assist the providers by
entering medication orders, great caution must be exercised when

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