decisionhealth Newsletters, Part B News - 2012 Issue 6 (June)
Template abuses: Allowing staff, not the physician, to complete HPI
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Article Overview
This article explains a common electronic health record template problem involving the history of present illness and the role of ancillary staff in documentation. It is aimed at physicians, non-physician practitioners, coders, compliance staff, and practice managers who oversee E/M documentation and EHR workflows. The discussion covers documentation responsibilities, potential billing impact, and practical workflow and access-control measures to reduce template misuse.
Why This Topic Matters
Misattributed or incomplete documentation can affect the reliability of an encounter record and may contribute to incorrect evaluation and management level assignment. Practices that use shared templates or multiple staff roles need to understand how documentation responsibilities and system permissions affect compliance and audit readiness.
What You Will Learn
- Why staff-entered history documentation can create compliance and billing concerns
- How EHR workflow and login practices can affect documentation integrity
- What kinds of practice controls may help reduce template misuse
- Why accurate identification of who documented what matters in E/M records
Who Should Read This
- Physicians
- Non-physician practitioners
- Medical coders
- Compliance officers
- Practice managers
- EHR administrators
- Billing staff
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