Page 18 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

Consider the following case:

C A S E S T U DY

A urologist, over the course of several office visits,

incorrectly carried over erroneous documentation
suggesting a positive study for an enlarging renal mass,

which was the basis for a radical nephrectomy. The post-
op pathology report revealed no such cancer. During the

deposition, the physician admitted to the documentation
errors that were the result of the copy and paste function

of the EHR system. While the physician’s failure to review
the study prior to taking the patient into surgery was

difficult to defend, the documentation errors called the
entire record, as well as the physician’s credibility, into

question.

PITFALL #3: AUTO-POPULATION

Auto-population allows the EHR system to pre-fill information
in specific areas of the medical record as a means of creating

a shortcut or improving the efficiency of the documentation
process. The practitioner must be aware of those areas of the

medical record that are auto-populated in order to know what
information will need to be reviewed and verified prior to signing

the note.

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