Get Up to Speed on Clinical Documentation Improvement for EMRs

Posted on 24 Apr, 2018 |comments_icon 0|By Elizabeth

The EMR is a dynamic document database, evolving every time a user accesses it. With today’s standard features and add-on conveniences, EMRs have the potential to save time, increase productivity, enhance efficiency, and play an important part in patient engagement. However, it is imperative that practices establish strong documentation guidelines specifically applicable to their EMR system, and then educate clinical staff on the existence and use of these standards, to help minimize documentation errors. We’ve already reviewed some of the drawbacks of documenting in an EMR. Let’s take a look at some more next.

It is now easier than ever for the provider to document in an EMR with the readily available checklists and templates it contains. But it also makes it easier to conduct the audit from the payer’s side.

Auditors can be brutal with discrepancies within EMR notes, as such errors are often indicators of serious concerns regarding the quality of care being delivered to the patient.

If an auditor discovers a contradiction in the ROS and the history of the patient’s illness, she will flag the file for further investigation.

Fast Facts about EMR Templates

Templates were designed to help clinicians increase productivity, organization, and streamline their work flow. However, it takes commitment and training, not to mention preparation, to set the EMR templates up the way the team wants – and needs – them to operate. Once templates are up and running, it’s not enough to sit back and let them go without monitoring: Providers must utilize the templates effectively and accurately, and practices should develop processes, training, and regular checking and monitoring for using the templates correctly.

Having ready-to-use templates is a good idea, however, providers should not rely solely on these aides to document in the patient’s record. Templates aren’t a foolproof, full-speed-ahead solution to a provider’s documentation needs. Providers have to thoroughly review documentation before signing off, including review of information entered into the EMR via a template to ensure accuracy.

Tip: Pre-printed forms, produced in bulk, outlining all of the information required, may be the best training guide possible for introducing providers to EMR templates. Once providers have been indoctrinated into the hardcopy version of the template and how to correctly use it, practice managers and CDI specialists can slowly wean them off of the hardcopy and onto the automated EMR templates.

Templates are NOT One-Size-Fits-All

While a personally customizable note template is a great idea on the surface, payers can easily deny claims if the templates across providers look too similar. A good form should be adjustable for each patient and should not create an exact duplicate record across several patients who all came in with the same key complaints.

All patients are unique in their treatment needs, and their records should be, too. A single template cannot adequately capture the care of all patients, and practices will need to adjust these forms on a regular basis based on practice and patient requirements.

Caution: Most payers and auditors are not in favor of templates and may often report their use in an audit report and scores.

Tip: CDI team members should note certain nuances or suggested changes to the template and discuss these revisions with the CDS or practice manager. Updates can be added as and when needed, based on the specific considerations of the patients of that practice.

EMR Templates: A Boon or a Bane?

Downside: As speedy and convenient as they are to operate, templates create their own set of problems. Attorneys are increasingly reporting that EMR systems are keeping them in business, and it’s the templates, across the board, that are the biggest culprit.

Physicians must fully document within the EMR using their own words, rather than letting the computer fill it out or auto-populate the record for them. Keep in mind, when providers dictated their notes, they had to carefully consider each patient encounter to provide enough detail for the transcriptionist. Now, the computer does the work for them. Even though the result looks similar, computers cannot match the scope of the clinician’s thought process 100 percent.

Hidden trap: Since the implementation of EMR systems, there has been an increase in concerns about documentation across providers and payers. The computerization of information in the medical record means a whole new set of errors that are foreign to handwritten paper documentation and dictated notes.

These unique types of errors have warranted greater exposure and increased scrutiny of claims, with the added risk to physicians of being accused of professional malpractice. And EMR systems are, of course, on the radar of CMS and the OIG.

Caution: Watch out for the self-populating fields, or “exploding” documentation feature, which add in all of the patient’s prior clinical history at the click of a checkbox. These fields may seem like a time-saving function, but incorrectly completing them can do great harm to a provider and, ultimately, his patients.

Mistake: Depending on which EMR the physician uses, she may inadvertently document a full assessment and ROS that she has yet to perform (or may not perform at all). If the physician does not take the time to review the documentation, the coder will code the services, which will then be billed to the payer, leading to incorrect reimbursement and a possible fraud investigation. Compounding this problem is the fact that documentation for subsequent encounters will also be impacted by the incorrect documentation.

Outsmart the Auto-Populate Feature in EMRs

In EMR, it’s easy to document a lot of information with just a few clicks. Even where a comprehensive history or exam is not really warranted, clicks can help repopulate or auto-populate content. However, the over-documentation of the history and physical (H&P) examination can lead to over-coding – especially for established patients and if the provider relies on the system to select the E/M code.

But if the template is correctly created and utilized, providers can document a comprehensive physical exam (PE) in short order, thereby saving a lot of time.

Experts warn: Auditors may question the medical necessity of a particular portion of the exam, so providers must substantiate a valid connection between the PE, ROS, and the presenting problem. Using auto-populate to document will save time, but the provider must always thoroughly review the documentation to ensure its accuracy before signing off on the record.

Learn More

Master accurate and timely documentation that reflects the scope of services provided with TCI’s Clinical Documentation Sourcebook 2018.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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