3 Disturbing EHR Causes for Poor Medical Documentation
EHRs, or electronic health records, have long been used to gain timely access to clinical data and improve medical billing and coding. They are also used to provide alerts and help healthcare practices avoid costly errors when coordinating care. However, there are number of EHR challenges that compromise the quality and effectiveness of the documentation generated. Some of these include cloning data from one record to another, upcoding to receive higher payment, and the inability to track which clinician entered or modified the data.
Let us look at each of these challenges in more detail to determine how best to address them:
Since documentation is often the most effective communication tool used between and by providers, all the data contained in them must be relevant, current, and readily accessible. Cloning is the practice of copying and pasting previously recorded information from an earlier note to a new note. Auto-fill and auto-populate functions in EHR software can improve provider documentation but can also be misused. Medical records must contain documentation that represents the needs of the patient at each visit. Simply altering the date on the EHR without documenting the actual details of the visit can lead to fraud. Even worse, copying such data can result in entering inaccurate or outdated information into the patient’s charts.
Entering irrelevant data for the most current examination generates masses of redundant data, which can make it difficult to follow the care received by the patient and obscure important information regarding the diagnosis or treatment administered. When practitioners clone information, erroneous information may enter the patient’s medical record. Inappropriate charges may then be billed to payers, resulting in fraudulent or duplicate claims.
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Upcoding, or over documentation, is the practice of entering false or irrelevant documentation to support the billing of a higher level of service than what was actually provided. It occurs when a healthcare provider bills for a higher CPT code and payment than the actual services warranted, resulting in an improper payment. When medical practitioners copy and paste data from previous encounters with the patient, they often bill payers and patients for double the services provided for both current and past visits. If incorrect information is entered into the EHR by simply clicking a checkbox or using the existing templates to auto-fill records, patients can be billed for more than they bargained for.
Medical practitioners need to go through all the documentation recorded for a patient to edit any incorrect or redundant entries. Without taking this additional measure, medical practices may be billing for more comprehensive services than were actually rendered, resulting in fraudulent charges.
Difficulty Tracking the Appropriate Clinician
Healthcare providers should establish safeguards to protect against human error, abuse, and fraud when entering or editing data in the EHR. Some safeguards including documenting which clinician entered the data to determine where the inaccuracies or data redundancies originated from. Also, without visual markers to help staff or the provider know whether they are working on the correct record, huge errors could creep in.
The medical records that are in the EHR should reflect an accurate picture of the patient’s condition, either as it changes over time or at admission. Without knowing which clinician was responsible for the incorrect data entry, it becomes hard to tackle the errors at their source. Not identifying the appropriate party could result in introducing unintended and overwhelming safety-related issues into the clinical environment.
Poor medical documentation stem from a number of causes. Cloning increases the odds of inaccurate or outdated information entering the system, while upcoding to bloat the documentation so as to increase the payments being billed can result in fraudulent claims, which can lead to legal repercussions. Also, not being able to track the appropriate clinician who is responsible for the incorrect data entries or duplicate records could mean that the problem will never be tackled at its root.
These 3 causes of poor medical documentation not only result in unsafe medical practices but also compromises the practice’s reputation as a legitimate and trusted healthcare provider. If you are looking to eliminate errors in your EHR system and tackle the cause of data discrepancies and redundancies at its root, trust MedBillingExperts to deliver a comprehensive solution to your complex business challenges.