Page 22 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Some practices continue to rely on a paper record even after the

adoption of an EHR. The use of a paper and EHR records for a

patient makes it impossible to identify a single source of truth for
the patient’s health information. Information in one or both records

can be incomplete or inaccurate which creates risk for the

provider as well as other providers covering for him or her. It

should also be noted that, increased likelihood of medical error

can occur during the conversion from a paper system to an

electronic system, or during upgrades within the electronic system.

Avoiding the pitfalls of inconsistent processes can only be

accomplished with office-wide focus on the creation of standard

processes for use with the EHR. Eliminate duplicating medical

record documentation in multiple systems. Select one system and
convert all medical records to the system chosen, and conduct

training to ensure staff and providers are knowledgeable and

proficient.

Cloned notes may have entries worded exactly like previous

entries, may lack specific individual information and may give the

appearance that every patient visit details the same exact problem,
the same symptoms and required the same exact treatment. If

notes are audited by Center for Medicare Services or a private

payer and notes appear to be cloned, this may raise red flags

about whether the actual care was provided to support the level of

coding billed.

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