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Three Ways to Document a Physician/Patient Visit in an EMR

Posted Oct 03 2012 12:00am

I came across a blog note that lists three general ways in which clinical notes pertaining to a physician visit with a patient in the hospital or office can be documented in an EMR (see:  Shock and Awe: EHRs Work as Designed ). This concept has taken on added significance of late due to recent news about the cloning of clinical notes in EMRs as a means to inappropriately increase Medicare reimbursement. Below is an excerpt from the note:

To make [automating and documenting a patient visit] most efficient, three methods of documentation have been developed to replace hand writing and to efficiently minimize the need for extensive box-clicking [in an EMR].

  • Documentation by ExceptionEvery EHR has this “feature” allowing the documenter to click on ONE box usually at the top of the page which generates a professional sounding clinical sentence for each organ or body part stating that everything is perfectly normal, or that all your histories are unremarkable in any way. This is a great efficiency to be applied presumably after the interviewer ascertained that all is well with your past and present relatives and body parts. If something is wrong with one or two organs, the clinician can click the Normal button and then edit the exceptional few organs that are affected today, thus obtaining documentation for a complete review or examination of all your systems. Remember that every organ and family member documented is worth a few more dollars according to Medicare’s fee-for-documentation model of reimbursement....
  • Pre-filled Templates – These go by different names, but they are a huge time saver for simple and common problems and here is how they work: Let’s say you see a patient with an URI and it is flu season. You document the visit de novo starting from a blank URI template, use all the previously described efficiencies and generate a lovely visit note for this patient....You can save this visit note as a pre-filled template sans patient demographics and histories....and when the next URI patient shows up, you can load this pre-filled template and edit exceptions, if any. Since technology is magical, EHRs will also load the patient specific histories and merge them into your brand new note automatically. Two or three clicks will get you enough documentation to allow your EHR to calculate a very nice E&M code and generate enough documentation to keep the payers at bay.
  • Bring Forward – ....We all know that not much changes in a few months and most likely everything you will be documenting today is exactly what you documented six months ago. Instead of starting from scratch every time, EHRs have created great efficiency by making it possible for the documenter to bring forward, or load, the previous visit note and allow him/her to edit and make changes based on today’s visit. This beats the old “copy & paste” by a mile, and with a click of a button you have all the organs and relatives and complexity of decision making documented in minute detail. You can now make a few changes here and there as necessary, and the EHR will calculate the appropriate E&M code.

So when exactly does an automated EMR feature designed to save time and energy when documenting physician care lead to a scam? The answer to this question seems obvious to me. A scam occurs when documentation in an EMR is generated automatically and with little or no forethought by the physician about the status of the patient. What is going through a physician's mind in such a setting is obviously hard to document. However, it often becomes evident ex post facto. For example, a note may indicate that a patient is doing well but lab or imaging studies performed at approximately the same time provide evidence to the contrary.

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