by Betty Stump, RHIT, CPC, CCS-P, CPMA
June 3rd, 2016
"As of the end of 2015, 56 percent of all U.S. office-based physicians (MD/DO) have demonstrated meaningful use of certified health IT in the Centers for Medicare and Medicaid Services (CMS) Electronic Health Record (EHR) Incentive Programs." 
More than half of the physicians in practice in the United States currently use some form of electronic health record to document and store their patients' medical records. While controversy still exists pertaining to the effectiveness and value of electronic medical records, there is no denying the fundamental shift in clinical documentation practices to an electronic format. There are many benefits to electronic health records (EMR/EHR) including improved legibility, access to patient records, greater ability to integrate and share electronic information across health systems and improvements to patient care through safer, more reliable prescribing practices and tracking of recommended health services for screening and prevention. There is a dark side to the use of electronic medical records however and it's critically important that physicians and office staff be aware and remain vigilant to some of the more common issues in documentation that may be a direct result of the use of an electronic documentation system.
EMR technology and 'click box' templates are a common shortcut allowing clinicians to record history or exam components with as little as one click of the computer mouse. The result is often a comprehensive review of systems(ROS), inclusion of a complete past, family and social history or even a comprehensive head to toe physical examination. Documentation of a comprehensive review of systems must be supported by the medical necessity of the patient's chief complaint and history of present illness. Routinely capturing a comprehensive ROS for all patient visits on every encounter strongly suggests unnecessary documentation performed simply to support the coding of a higher level of service. CMS guidelines very clearly state "the volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported." 
Other concerns for EMR's with regard to history include routine use of the phrase "all others negative", "a complete review of systems is otherwise negative except as noted in the HPI", routine importing of complete past family and social history into every progress note or the use of "noncontributory" when documenting family history. Clinicians must recognize when they document a complete review of systems through phrases such as 'all others negative', they are attesting to the fact that they reviewed all 14 systems during the patient encounter. Physicians should never document services not performed - if it wasn't done, don't say that it was!
Documentation Inconsistent with Chief Complaint:
CERT findings issued by regional Medicare Administrative Contractors (MACs) consistently cite a top 10 error finding for documentation not supporting the level of service reported. Medical record documentation should clearly correlate between the chief complaint, the history of present illness, the extent of the exam performed and what is documented for medical decision-making. EMR templating issues that restrict or prevent providers from recording specific clinically relevant information for the history of present illness and the assessment and plan of care may result in flawed or incorrect documentation. Examples of inconsistency in the medical record include:
Chief complaint for knee pain however a final disposition is noted for GERD.
Chief complaint of vomiting and abdominal pain, G.I. ROS noted as negative, exam noted as unremarkable and a discharge diagnosis of acute gastroenteritis.
Chief complaint of rash and history of present illness notes rash has been present for 'one to four weeks'. (This is a definite clinical concern - surely the physician knows more specifically if the rash has been present for a few days or for an entire month?)
Assessment and Plan of Care is a Diagnosis List:
EMR technology must allow a provider to record not only the condition or diagnosis but also the current status and the plan of care for treatment. CMS documentation guidelines specify the medical record should include the clinician's assessment, clinical impression, or diagnosis and medical plan of care for each patient encounter. This includes the patient's progress, response to and changes in treatment, and revision of diagnoses in the medical record. Documentation that contains only a 'laundry- list' of diagnoses (ICD-10-CM code and description) doesn't fulfill this basic documentation requirement.
Templated Examination Elements:
The extent and detail of the physical examination performed is based on the providers' clinical judgment and should be relevant to the patient's chief complaint and history of present illness. Many EMR's are designed to follow examination bullet points specific to the 1997 documentation guidelines. Particularly for specialty offices such as cardiology, neurology, dermatology and ophthalmology, it's vitally important to ensure that ALL the bullet points necessary for a comprehensive examination are included in the template. Failing to include all necessary components will result in documentation likely to never to support a comprehensive level of exam.
Ensuring Final Output:
Lastly, physicians and medical office administrators should perform periodic checks of the final documentation generated by their EMR system. The clinical input view of an electronic medical record has little or no resemblance to the final output produced by the program. During compliance audits, we've had occasions when the medical record provided was incomplete or didn't support the level of service reported. It's only after the audit was completed we discovered documentation provided for the audit was a 'draft' view or some other form of temporary file within the EMR system. We've also uncovered situations where complete physician free text entries were not captured and produced in the final document. The final print output from an electronic medical record system is the medical record provided to outside clinicians, other healthcare entities and for payer/audit review. EMR systems that don't produce a complete record, consistent and containing true and valid entries into the medical record, may be responsible for documentation that reflects inappropriate or poor physician clinical standards of care. Don't let your electronic health record system make you look like a bad doctor!
Office of the National Coordinator for Health Information Technology. 'Office-based Health Care Professionals Participating in the CMS EHR Incentive Programs,' Health IT Quick-Stat #44. dashboard.healthit.gov/quickstats/pages/FIG- Health-Care-Professionals-EHR-Incentive- Programs.php. February 2016.
 Per Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100- 04, Chapter 12, section 30.6.1