decisionhealth Newsletters, Part B News - 2006 Issue 5 (May)
5 steps to keep your software from creating E/M trouble
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Article Overview
This article explains how electronic medical record software can create documentation and coding problems if default settings, templates, training, and automated code selection are not managed carefully. It is aimed at clinicians, coders, billers, compliance staff, and practice managers who use EMR systems and want general guidance on avoiding audit and documentation issues. The discussion focuses on broad risk areas in electronic documentation and human review processes rather than on specific patient cases or coding rules.
Why This Topic Matters
Electronic documentation tools can improve efficiency, but they can also create patterns that draw audit scrutiny or support unsupported coding if they are not controlled appropriately. Understanding the general risks helps practices use EMR software more safely and maintain documentation integrity.
What You Will Learn
- Common ways EMR defaults can affect documentation quality
- Why template use should be individualized for each patient
- How standardized chart language can create audit concerns
- The importance of training all EMR users in a practice
- Why human review remains important when software suggests codes
Who Should Read This
- Physicians
- Coders
- Billers
- Compliance professionals
- Practice managers
- Health information management staff
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