decisionhealth Newsletters, Part B News - 2012 Issue 8 (August)
Template abuses: Be careful using information from previous notes
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Article Overview
This article reviews common documentation pitfalls related to electronic health record template use, especially when prior note content is carried forward into a new encounter. It is aimed at physicians, practice administrators, and coding/compliance staff who review documentation quality and want to avoid audit issues tied to electronic records, review of systems, and past medical/family/social history entries. The article covers general safeguards for signing, dating, reviewing, and selectively importing prior information in EHR systems.
Why This Topic Matters
Reused or improperly updated note content can affect the supportability of the current encounter’s documentation and create risk during audit review. Understanding these template and EHR workflow issues helps practices improve documentation integrity.
Article Sections
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The problem
Introduces concerns about repeating prior note language in current documentation and describes the general documentation risk involved.
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Electronic health records
Places the topic in the context of EHR template use and a series of articles about common template-related issues.
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The solutions
Summarizes recommended workflow and EHR features that can help practices better review and manage imported note content.
What You Will Learn
- How reused information from prior notes can create documentation concerns
- Why EHR template workflows can affect the reliability of current visit notes
- General practices that may improve review, signing, and editing of imported documentation
- What types of EHR functionality can help clinicians manage copied note content
Who Should Read This
- Physicians
- Medical coders
- Compliance staff
- Practice managers
- EHR users
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