EMR not a substitute for good documentation

Article Overview

This article discusses the relationship between electronic medical recordkeeping and documentation quality in physician practices. It explains why compliance consultants view documentation as especially important in EMR environments, how cloned notes and template-driven records can raise audit concerns, and how specialty groups such as pediatrics and family medicine are responding to payer scrutiny and E/M coding changes. The piece is relevant to coders, compliance staff, physicians, and practice managers who want to understand documentation risk in an electronic health record setting.